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Meta-Analysis
. 2017 Nov 3;11(11):CD005661.
doi: 10.1002/14651858.CD005661.pub2.

Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications

Sunil V Patel  1 , David D Paskar, Richard L Nelson, Satyanarayana S Vedula, Scott R Steele
Affiliations
Meta-Analysis

Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications

Sunil V Patel et al. Cochrane Database Syst Rev. .

Abstract

Background: Surgeons who perform laparotomy have a number of decisions to make regarding abdominal closure. Material and size of potential suture types varies widely. In addition, surgeons can choose to close the incision in anatomic layers or mass ('en masse'), as well as using either a continuous or interrupted suturing technique, of which there are different styles of each. There is ongoing debate as to which suturing techniques and suture materials are best for achieving definitive wound closure while minimising the risk of short- and long-term complications.

Objectives: The objectives of this review were to identify the best available suture techniques and suture materials for closure of the fascia following laparotomy incisions, by assessing the following comparisons: absorbable versus non-absorbable sutures; mass versus layered closure; continuous versus interrupted closure techniques; monofilament versus multifilament sutures; and slow absorbable versus fast absorbable sutures. Our objective was not to determine the single best combination of suture material and techniques, but to compare the individual components of abdominal closure.

Search methods: On 8 February 2017 we searched CENTRAL, MEDLINE, Embase, two trials registries, and Science Citation Index. There were no limitations based on language or date of publication. We searched the reference lists of all included studies to identify trials that our searches may have missed.

Selection criteria: We included randomised controlled trials (RCTs) that compared suture materials or closure techniques, or both, for fascial closure of laparotomy incisions. We excluded trials that compared only types of skin closures, peritoneal closures or use of retention sutures.

Data collection and analysis: We abstracted data and assessed the risk of bias for each trial. We calculated a summary risk ratio (RR) for the outcomes assessed in the review, all of which were dichotomous. We used random-effects modelling, based on the heterogeneity seen throughout the studies and analyses. We completed subgroup analysis planned a priori for each outcome, excluding studies where interventions being compared differed by more than one component, making it impossible to determine which variable impacted on the outcome, or the possibility of a synergistic effect. We completed sensitivity analysis, excluding trials with at least one trait with high risk of bias. We assessed the quality of evidence using the GRADEpro guidelines.

Main results: Fifty-five RCTs with a total of 19,174 participants met the inclusion criteria and were included in the meta-analysis. Included studies were heterogeneous in the type of sutures used, methods of closure and patient population. Many of the included studies reported multiple comparisons.For our primary outcome, the proportion of participants who developed incisional hernia at one year or more of follow-up, we did not find evidence that suture absorption (absorbable versus non-absorbable sutures, RR 1.07, 95% CI 0.86 to 1.32, moderate-quality evidence; or slow versus fast absorbable sutures, RR 0.81, 95% CI 0.63 to 1.06, moderate-quality evidence), closure method (mass versus layered, RR 1.92, 95% CI 0.58 to 6.35, very low-quality evidence) or closure technique (continuous versus interrupted, RR 1.01, 95% CI 0.76 to 1.35, moderate-quality evidence) resulted in a difference in the risk of incisional hernia. We did, however, find evidence to suggest that monofilament sutures reduced the risk of incisional hernia when compared with multifilament sutures (RR 0.76, 95% CI 0.59 to 0.98, I2 = 30%, moderate-quality evidence).For our secondary outcomes, we found that none of the interventions reduced the risk of wound infection, whether based on suture absorption (absorbable versus non-absorbable sutures, RR 0.99, 95% CI 0.84 to 1.17, moderate-quality evidence; or slow versus fast absorbable sutures, RR 1.16, 95% CI 0.85 to 1.57, moderate-quality evidence), closure method (mass versus layered, RR 0.93, 95% CI 0.67 to 1.30, low-quality evidence) or closure technique (continuous versus interrupted, RR 1.13, 95% CI 0.96 to 1.34, moderate-quality evidence).Similarily, none of the interventions reduced the risk of wound dehiscence whether based on suture absorption (absorbable versus non-absorbable sutures, RR 0.78, 95% CI 0.55 to 1.10, moderate-quality evidence; or slow versus fast absorbable sutures, RR 1.55, 95% CI 0.92 to 2.61, moderate-quality evidence), closure method (mass versus layered, RR 0.69, 95% CI 0.31 to 1.52, moderate-quality evidence) or closure technique (continuous versus interrupted, RR 1.21, 95% CI 0.90 to 1.64, moderate-quality evidence).Absorbable sutures, compared with non-absorbable sutures (RR 0.49, 95% CI 0.26 to 0.94, low-quality evidence) reduced the risk of sinus or fistula tract formation. None of the other comparisons showed a difference (slow versus fast absorbable sutures, RR 0.88, 95% CI 0.05 to 16.05, very low-quality evidence; mass versus layered, RR 0.49, 95% CI 0.15 to 1.62, low-quality evidence; continuous versus interrupted, RR 1.51, 95% CI 0.64 to 3.61, very low-quality evidence).

Authors' conclusions: Based on this moderate-quality body of evidence, monofilament sutures may reduce the risk of incisional hernia. Absorbable sutures may also reduce the risk of sinus or fistula tract formation, but this finding is based on low-quality evidence.We had serious concerns about the design or reporting of several of the 55 included trials. The comparator arms in many trials differed by more than one component, making it impossible to attribute differences between groups to any one component. In addition, the patient population included in many of the studies was very heterogeneous. Trials included both emergency and elective cases, different types of disease pathology (e.g. colon surgery, hepatobiliary surgery, etc.) or different types of incisions (e.g. midline, paramedian, subcostal).Consequently, larger, high-quality trials to further address this clinical challenge are warranted. Future studies should ensure that proper randomisation and allocation techniques are performed, wound assessors are blinded, and that the duration of follow-up is adequate. It is important that only one type of intervention is compared between groups. In addition, a homogeneous patient population would allow for a more accurate assessment of the interventions.

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Conflict of interest statement

SVP: none DP: none RN: none SSV: none SS: none

Figures

1
1
Study flow diagram
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study
4
4
Funnel plot of comparison 1. Absorbable suture versus non‐absorbable sutures (any closure or technique), outcome 1.1: hernia
5
5
Funnel plot of comparison 3. Continuous versus interrupted closure, outcome 3.1: incisional hernia
6
6
Funnel plot of comparison 4. Monofilament versus multifilament sutures, outcome 4.1: incisional hernia
1.1
1.1. Analysis
Comparison 1 Absorbable sutures versus non‐absorbable sutures (any closure or technique), Outcome 1 Incisional hernia.
1.2
1.2. Analysis
Comparison 1 Absorbable sutures versus non‐absorbable sutures (any closure or technique), Outcome 2 Wound infection.
1.3
1.3. Analysis
Comparison 1 Absorbable sutures versus non‐absorbable sutures (any closure or technique), Outcome 3 Wound dehiscence.
1.4
1.4. Analysis
Comparison 1 Absorbable sutures versus non‐absorbable sutures (any closure or technique), Outcome 4 Sinus or fistula formation.
1.5
1.5. Analysis
Comparison 1 Absorbable sutures versus non‐absorbable sutures (any closure or technique), Outcome 5 Hernia and type of incision.
2.1
2.1. Analysis
Comparison 2 Mass versus layered closure, Outcome 1 Incisional hernia.
2.2
2.2. Analysis
Comparison 2 Mass versus layered closure, Outcome 2 Wound infection.
2.3
2.3. Analysis
Comparison 2 Mass versus layered closure, Outcome 3 Wound dehiscence.
2.4
2.4. Analysis
Comparison 2 Mass versus layered closure, Outcome 4 Sinus or fistula formation.
3.1
3.1. Analysis
Comparison 3 Continuous versus interrupted closure, Outcome 1 Incisional hernia.
3.2
3.2. Analysis
Comparison 3 Continuous versus interrupted closure, Outcome 2 Wound infection.
3.3
3.3. Analysis
Comparison 3 Continuous versus interrupted closure, Outcome 3 Wound dehiscence.
3.4
3.4. Analysis
Comparison 3 Continuous versus interrupted closure, Outcome 4 Sinus or fistula formation.
3.5
3.5. Analysis
Comparison 3 Continuous versus interrupted closure, Outcome 5 Hernia and type of incision.
4.1
4.1. Analysis
Comparison 4 Monofilament versus multifilament sutures, Outcome 1 Incisional hernia.
4.2
4.2. Analysis
Comparison 4 Monofilament versus multifilament sutures, Outcome 2 Wound infection.
4.3
4.3. Analysis
Comparison 4 Monofilament versus multifilament sutures, Outcome 3 Wound dehiscence.
4.4
4.4. Analysis
Comparison 4 Monofilament versus multifilament sutures, Outcome 4 Sinus or fistula formation.
4.5
4.5. Analysis
Comparison 4 Monofilament versus multifilament sutures, Outcome 5 Hernia and type of incision.
5.1
5.1. Analysis
Comparison 5 Slow absorbable versus fast absorbable sutures (any technique), Outcome 1 Incisional hernia.
5.2
5.2. Analysis
Comparison 5 Slow absorbable versus fast absorbable sutures (any technique), Outcome 2 Wound infection.
5.3
5.3. Analysis
Comparison 5 Slow absorbable versus fast absorbable sutures (any technique), Outcome 3 Wound dehiscence.
5.4
5.4. Analysis
Comparison 5 Slow absorbable versus fast absorbable sutures (any technique), Outcome 4 Sinus or fistula formation.
6.1
6.1. Analysis
Comparison 6 Sensitivity analysis: excluding high‐risk studies, Outcome 1 Incisional hernia (absorbable versus non‐absorbable suture, same technique).
6.2
6.2. Analysis
Comparison 6 Sensitivity analysis: excluding high‐risk studies, Outcome 2 Incisional hernia (continuous versus interrupted, same material and method).
6.3
6.3. Analysis
Comparison 6 Sensitivity analysis: excluding high‐risk studies, Outcome 3 Incisional hernia (monofilament versus multifilament, same technique).
7.1
7.1. Analysis
Comparison 7 Sensitivity analysis: inclusion of missing data, assuming loss to follow‐up developed incisional hernia, Outcome 1 Absorbable versus non‐absorbable (hernia).
7.2
7.2. Analysis
Comparison 7 Sensitivity analysis: inclusion of missing data, assuming loss to follow‐up developed incisional hernia, Outcome 2 Mass versus layered closure (hernia).
7.3
7.3. Analysis
Comparison 7 Sensitivity analysis: inclusion of missing data, assuming loss to follow‐up developed incisional hernia, Outcome 3 Continuous versus interrupted.
7.4
7.4. Analysis
Comparison 7 Sensitivity analysis: inclusion of missing data, assuming loss to follow‐up developed incisional hernia, Outcome 4 Monofilament versus multifilament (hernia).
7.5
7.5. Analysis
Comparison 7 Sensitivity analysis: inclusion of missing data, assuming loss to follow‐up developed incisional hernia, Outcome 5 Slow absorbable versus fast absorbable (hernia).
8.1
8.1. Analysis
Comparison 8 Sensitivity analysis: inclusion of missing data, assuming loss to follow‐up did not have developed incisional hernia, Outcome 1 Absorbable versus non‐absorbable (hernia).
8.2
8.2. Analysis
Comparison 8 Sensitivity analysis: inclusion of missing data, assuming loss to follow‐up did not have developed incisional hernia, Outcome 2 Mass versus layered closure (hernia).
8.3
8.3. Analysis
Comparison 8 Sensitivity analysis: inclusion of missing data, assuming loss to follow‐up did not have developed incisional hernia, Outcome 3 Continuous versus interrupted.
8.4
8.4. Analysis
Comparison 8 Sensitivity analysis: inclusion of missing data, assuming loss to follow‐up did not have developed incisional hernia, Outcome 4 Monofilament versus multifilament (hernia).
8.5
8.5. Analysis
Comparison 8 Sensitivity analysis: inclusion of missing data, assuming loss to follow‐up did not have developed incisional hernia, Outcome 5 Slow absorbable versus fast absorbable (hernia).
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Update of

  • doi: 10.1002/14651858.CD005661

References

References to studies included in this review

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Gys 1989 {published data only}
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Hsiao 2000 {published data only}
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Irvin 1976 {published data only}
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Irvin 1977 {published data only}
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Israelsson 1994 {published data only}
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Kiely 1985 {published data only}
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Kronborg 1976 {published data only}
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Krukowski 1987 {published data only}
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Larsen 1989 {published data only}
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Leaper 1977 {published data only}
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Leaper 1985 {published data only}
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Lewis 1989 {published data only}
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McNeill 1986 {published data only}
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Orr 1990 {published data only}
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Trimbos 1992 {published data only}
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References to studies excluded from this review

Agarwal 2011 {published and unpublished data}
    1. Agarwal A, Hossain Z, Agarwal A, Das A, Chakraborty S, Mitra N, et al. Reinforced tension line suture closure after midline laparotomy in emergency surgery. Tropical Doctor 2011;41(4):193‐6. - PubMed
Atul Kumar 2005 {published data only}
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Baracs 2011 {published and unpublished data}
    1. Baracs J, Huszar O, Sajjadi SG, Horvath OP. Surgical site infections after abdominal closure in colorectal surgery using triclosan‐coated absorbable suture (PDS Plus) vs. uncoated sutures (PDS II): a randomized multicenter study. Surgical Infections 2011;12(6):483‐9. - PubMed
Cengiz 2001 {published data only}
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Deerenberg 2015 {published and unpublished data}
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References to ongoing studies

ISRCTN25616490 {unpublished data only}
    1. ISRCTN25616490. Hughes Abdominal Repair Trial (HART) ‐ abdominal wall closure techniques to reduce the incidence of incisional hernias: study protocol for a randomised controlled trial. www.isrctn.com/ISRCTN25616490 2016. - PMC - PubMed
NCT00514566 {unpublished data only}
    1. NCT00514566. PDS vs. polyamide for midline abdominal closure PPMAC. clinicaltrials.gov/ct2/show/NCT00514566.
NCT00544583 {published and unpublished data}
    1. NCT00544583. Continuous versus interrupted abdominal wall closure after emergency midline laparotomy (CONTINT). clinicaltrials.gov/ct2/show/NCT00544583 2010. - PMC - PubMed
NCT01965249 {unpublished data only}
    1. NCT01965249. Short stitch versus long stitch suture technique using monomax for abdominal wall closure after primary median laparotomy. A randomized controlled, double blinded, multicenter international trial. clinicaltrials.gov/ct2/show/NCT01965249.
NCT02145052 {unpublished data only}
    1. NCT02145052. Optimal method of fascial closure in high risk patients undergoing laparotomy: a prospective randomized trial. clinicaltrials.gov/ct2/show/NCT02145052.
TCTR20150318001 {unpublished data only}
    1. TCTR20150318001. Randomized trial to compare dehiscence with continuous versus interrupted mass closure of transverse incisions in children with absorbable suture (CLOSE). www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&amp....

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