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ABDOMINAL WALL ANATOMY & FASCIA
CLOSURE
Dr. Vikram Jaisinghani
Big Picture
Training:
PDS PLUS Sutures
8
/
Agenda
Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
Anterior Abdominal Wall (AAW) Anatomy
AAW Complications & factors affecting healing
8 Strategies to reduce complications
Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
Anterior Abdominal Wall (AAW) Anatomy
AAW Complications & factors affecting healing
8 Strategies to reduce complications
Skin
8
/
Skin
Epidermis: provides waterproofing and serves as a barrier to infection, no blood vessels
Dermis: location for the appendages of skin
Connective tissue
Basement membrane (anchors dermis)
Nerve endings (touch/heat)
Sweat glands
Sebaceous glands
Apocrine glands
Hair follicles
Lymphatic vessels
Blood vessels
8
/
Basic Anatomy of Skin and Fascia
Epidermis
Dermis
Subcutaneous
tissue (fat)
Fascia/Muscle
Skin and Fascia
1
2
1 = skin and subcutaneous tissue; 2 = fascia
Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
Anterior Abdominal Wall (AAW) Anatomy
AAW Complications & factors affecting healing
8 Strategies to reduce complications
Wound healing
10
Classification of wounds
Types of wound healing
Phases of wound healing
Factors that influence wound healing
Abrasions
Bites
Burns
Lacerations
Punctures
Incisions
Classification of Acute Skin Wounds
Surgical
Strecker-McGraw et al. Emerg Med Clin North Am. 2007;25:1-22.
Traumatic
Traumatic Wounds and Lacerations
Traumatic wounds are common and bear extensive medical costs US >26 million/year = $35 billion1,2
EU >42 million/year = €15 billion3
Physical exam should be careful and meticulous4
Time and mechanism of injury
Potential for infection
Hemostasis
Foreign bodies
Timeframe for closure: maximum of 24 hours from the time of injury5
1. National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary.
2. CDC NEISS All Injury Program 2005 Results.
3. EU Injury Database Report 2009.
4. Lammers. Principles of wound management. In: Roberts and Hedges. Clinical Procedures in Emergency Medicine. 5th ed.
Saunders Press; 2010.
5. Pfaff and Moore. Emerg Med Clin North Am. 2007;25:189.
‒ Tendon, vascular, and joint injuries
‒ Neurovascular exam
‒ Patient history
13
Classification of wounds
Bacterial presence:
• Contamination: Bacteria are present, but not proliferating
• Colonization: Bacteria proliferating without host reaction
• Infected tissue: Deposition and proliferation of micro-
organisms in the organism, with consequent host reaction
Defining Wound Healing
A “healed wound” is one where1
Connective tissues have been repaired and
Wound has been completely epithelialized by regeneration that has returned to its normal anatomic structure and function without the need for continued drainage or dressing
Some wounds fail to heal properly - chronic, non-healing wounds- need continued management2
Aberrations in certain phases of healing -result in excessive healing (hypertrophic scars, keloids)2
1. Enoch SE and Leaper DJ. Surgery. 2008;26:31-37.
2. Ethridge RT, Leong M and Phillips LG. Wound Healing. In: Townsend CM, Beauchamp RD, Evers BM and Mattox KL, eds.
Sabiston Textbook of Surgery. 18th ed. Saunders, 2007:191-216.
Types of Wound healing
Wounds or incisions can heal in different ways: Primary healing
- direct wound healing without complications (wound is closed with sutures)
- Secondary healing - indirect wound healing with complications; wound edges are
not approached with sutures - Spaces between the wound edges are filled by granulation
Tissue Tertiary healing - wound is filled by granulation tissue & is infection free (wound edges are approximated with sutures)
8
/
Clean incision
Primary healing/healing by primary intention Wound is closed within 12-24 hours
Examples: clean surgical incision,
clean laceration
Result: optimal cosmetic outcome
Delayed primary healing
Delineated wound that is closed after a few days having been left open to prevent infection
Examples: bites, abdominal wounds after peritoneal soiling
May result in scarring
Secondary healing (healing by secondary intention)
Wound with extensive loss of soft tissue
Examples: trauma, severe burns, open abdomen
May result in scarring
Three Major Types of Wound Healing
Ethridge et al. Wound healing. In: Townsend et al, eds. Sabiston Textbook of Surgery. 18th ed. Saunders; 2007.
Stages of Primary Wound healing
Exudative /Inflammatory phase Proliferative phase Remodeling phase
0-5 days
suture material is the
sole factor in holding
together the wound
Suture – high tensile
strength
5- 14 Days
stabilization of
the wound
closure is
gradually taken
over by
collagen
Suture- highest
tensile strength
7-14 days to a
year
suture material
becomes
irrelevant
Foreign
material- side
effects
1. Exudative/Inflammatory phase: 0 - 5 days
Suture Material is responsible for the adaptation of the wound
hours
Phases of Primary wound healing
4-6 days
Phases of Primary wound healing
2. Proliferative phase: 5-14 days
Collagen grows in and increases the stability of the wound
weeks
Phases of Primary wound healing
3. Reparative phase: 21 days – 1 year
Any foreign material can cause side effects
The Phases of Wound Healing
ECM = extracellular matrix; MMP = metalloproteinases; TIMP = tissue inhibitors of metalloproteinases.
Enoch S and Leaper DJ. Surgery. 2008;26:31-37.
0.1 0.3 1 3 10 30 100 300
Days after wounding (log scale)
Further synthesis
of ECM
MMP and TIMP activity
IV Remodelling and scar formation
Maxim
um
resp
on
se
V S
car
matu
ration
Neutrophils
Phagocytosis
Lymphocytes
Macrophages
II Inflammatory phase
ECM formation
Angiogenesis and
granulation tissue
formation
Re-epithelialization
C
oa
gu
latio
n
P
late
let a
ctiva
tio
n
I H
em
osta
sis
Alterations in one or more of these
phases could result in chronic wounds
Abnormalities in these phases result
in hypertrophic scars and keloids
III Proliferative phase
Cytokines and growth factors
Stages of Secondary Wound healing
Exudative (inflammatory) phase Proliferative phase Remodeling Phase
8
/
Weeks Months Days
“Tenets of Halsted” Continue to Guide Surgeons
Gentle handling of tissue
Aseptic technique
Sharp anatomic dissection of tissue
Careful hemostasis, using fine, nonirritating suture material in minimal amounts
Obliteration of dead space in the wound
Avoidance of tension
Foy HM, Evans SRT. Teaching technical skills-Errors in the process. In: Grand SRT. Surgical Pitfalls: Prevention and
Management. Saunders; 2009:11-22.
Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
Anterior Abdominal Wall (AAW) Anatomy
AAW Complications & factors affecting healing
8 Strategies to reduce complications
Factors Influencing Wound Healing
Operative/
Surgeon
Factors
Tissue
Factors
Patient
Factors
Wound
Healing
Classification of Factors That May Impede Wound Healing
Advanced age
Metabolic factors
Immunosuppression/ persisting disease
Deficiency syndromes
Shock of any cause
Infection
Presence of foreign body and foreign body reactions
Increased skin tension
Blood supply
Continued presence of micro-organisms
Infection
Systemic Local
Leaper. Basic surgical skills and anastomoses. In: Bailey and Love’s Short Practice of Surgery. 25th ed.
Edward Arnold Ltd; 2008.
Factors Leading to Risk of Compromised Healing
Advanced age (>70 years old)
Obesity
Smoking
Poor glucose control or hyperglycemia
Diabetes (type 1/2)
Nutritional or immunologic impairment
Low serum albumin concentration
A patient with even ONE of these risk factors is at greater risk of developing a surgical site infection (SSI)
1.Mangram AJ et al. Am J Infect Control Hosp Epidemiol. 1999;27:97-134.
2.NICE Clinical Guideline. October 2008.
3.World Health Organization. WHO Guidelines for Safe Surgery 2009. 2009.
Some Wounds Are More Likely to be Infected
Wounds are generally classified into 4 categories1:
Class 1 = Clean
Class 2 = Clean contaminated
Class 3 = Contaminated
Class 4 = Dirty infected
Contaminated or dirty/infected wound classifications are independently associated with increased risk of SSI1
1.Mangram et al. Infect Control Hosp Epidemiol. 1999;20:247-277.
Class Definition
I – Sterile
(Clean)
• No trauma effect
• No inflammation
• No breach of sterility
• Tracheobronchial system, GI tract and urogenital
tract intact
II – Mildly
contaminated
(Clean-
contaminated)
• Opening of the GI tract
• Appendectomy
• Opening of the oropharynx
• Opening of the vagina
• Opening of the urinary tract collecting system for
sterile urine
• Opening of the bile system with sterile bile
• minimal breach of sterility 29
Classification of wounds based on infection
Class Definition
III – Strongly
Contaminated
(Contaminated)
• Opening of the lower GI tract
• Traumatic wounds
• Opening of the collecting system with infected urine
• Opening of bile ducts with infected bile
• Breach of sterility
IV – Infected
(Dirty)
• Bacterial infection in OP area
• Draining of abscesses
• Traumatic wounds with necrosis, foreign bodies and
exit of faeces
• Old wounds
• Bite wounds or similar
30
Classification of wounds based on infection
Suture Contamination Can Increase Risk of Infection
Biofilms: every suture acts as a medical implant, increasing the risk of infection via bacterial colonization1
A B
C D
1. Mangram et al. Infect Control Hosp Epidemiol. 1999;20:247-277.
2. Suzuki T et al. J Clin Microbiol. 2007;45:3833-3836.
Local Tissue Trauma Can Impede Healing
Tissue trauma can result from:
Devices used for closure
Handling of tissue
Proper Suturing Technique: Critical Components of Wound Healing
Wound edges should be left slightly gaping to allow swelling
Edges should be everted
The knot should be placed to one side of the wound
Knots must be secure, with the ends long enough to grasp if the suture is to be removed
Use “no touch” technique whenever possible
Use appropriate needle holders
Leaper D. Basic surgical skills and anastomoses. In: Bailey and Love’s Short Practice of Surgery. 25th ed.
Edward Arnold Ltd; 2008.
Tissue Specific Healing Time Guides the Choice of Tissue Repair Material
14-28 days
7-14 days
7-14 days
8-12 weeks
*Minimum healing times shown here are for healthy individuals without medical complications.
14-28 days
7-14 days
7-14 days
8-12 weeks
Weeks
5-7 days
5-7 days
Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
Anterior Abdominal Wall (AAW) Anatomy
AAW Complications & factors affecting healing
8 Strategies to reduce complications
Examples of Wound Healing Complications
Dehiscence Infection Scarring
Images courtesy of David Leaper, MD.
Wound Healing Complications: Scar Formation
Typical scar characteristics
Flat surface
Narrow
Matches skin color
Harahap (ed). Surgical Techniques for Cutaneous Scar Revision. Marcel Dekker; 2000:81-106.
Téot. Wound Repair Regen. 2002;10:93-97.
Elevated Depressed Hypertrophic Keloids
Complicated scars
Wound Healing Complications: Dehiscence
Mechanism may be an underlying wound healing problem or surgical
technique
Surgical site infection (SSI) is a
major risk factor for dehiscence
Images courtesy of David Leaper, MD
Lammers. Principles of Wound Management. In Robert’s Clinical Procedures in Emergency Medicine. Saunders Press. 2010.
Wound Healing Summary
Healing of acute wounds: a complex, dynamic series of events
Optimal wound healing by primary intention; not possible in all cases
Many factors delay or impede wound healing: long-term complications-steps can be taken to ensure best outcomes
SSI prevention is a critical factor in achieving optimal acute and long-term wound healing
Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
Anterior Abdominal Wall (AAW) Anatomy
AAW Complications & factors affecting healing
8 Strategies to reduce complications
8
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Anterior Abdominal Wall
&
Fascia Anatomy
Basic Anatomy of Skin and Fascia
Epidermis
Dermis
Subcutaneous
tissue (fat)
Fascia/Muscle
Skin and Fascia
1
2
1 = skin and subcutaneous tissue; 2 = fascia
Anterior Abdominal Wall Anatomy
General Characteristics:
Three large flat sheets of muscle connecting rib
cage to hip bone (pelvis).
Muscular posteriorly and laterally.
Aponeurotic anteriorly and medially.
Muscle layers:
o External oblique.
o Internal oblique.
o Transversus abdominus.
o Rectus abdominus.
Anterior Abdominal Wall
Abdominal Wall: Muscles (I)
Consists of Three broad thin sheets that are aponeurotic in front
From exterior to interior they are:
- External oblique
- Internal oblique
- Transverse abdominus
A wide vertical muscle lies on either side of the midline anteriorly:
- Rectus abdominis muscle
Abdominal Wall: Muscles (II)
As the aponeurosis of three sheets pass forward, they enclose the rectus abdominis to form the rectus sheath
The cremaster muscle which is derived from the lower fibers of internal oblique, passes inferiorly as a covering of the spermatic cord and enters scrotum
Abdominal Wall: Muscles (III)
External Oblique Muscle: Is a broad, thin, muscular sheet Origin: Lower 8 ribs Insertion: Xiphoid process, linea alba, pubic tubercle, iliac crest Action: Supports abdominal contents, assist in forced expiration,
micturition (passing urine), defecation, parturition, vomiting
Internal Oblique Muscle: Origin: Lumbar fascia, iliac crest, lateral two-thirds of inguinal
ligament Insertion: Lower three ribs and costal cartilages, xiphoid process,
linea alba, symphysis pubis Action: Supports abdominal contents, assist in forced expiration,
micturition, defecation, parturition, vomiting
External Oblique Muscle Xiphoid process
Pubic symphysis &
tubercle
(middle part of the
pelvic or hip bone)
Costal margin (lower
margin of the rib cage)
Anterior Superior
Iliac Spine
Abdominal Wall: Muscles (IV)
Transversus Abdominus muscle:
Origin: Lower six costal cartilages, lumbar fascia, iliac crest, lateral third of inguinal ligament
Insertion: Xiphoid process, linea alba, symphysis pubis
Action: Compresses abdominal contents
Rectus Abdominus muscle: Origin: Symphysis pubis and pubic crest
Insertion: 5th, 6th and 7th costal cartilages and xiphoid process
Action: Compresses abdominal contents, flexes vertebral column, accessory muscle of expiration
Internal Obliques & Rectus Abdominus
Xiphoid process
Pubic symphysis &
tubercle
(middle part of the
pelvic or hip bone)
Costal margin
(lower margin of
the rib cage)
Anterior Abdominal Wall: Cross Section
54
Tissue layers of the abdominal wall
1. Skin : Epidermis
2. Subcutaneous : Fat layer underneath skin
3. Fascia : Connective tissue layer covering muscle
4. Muscles : Fibrous tissue strand 5. Peritoneum : Serous membrane that forms the lining of abdominal cavity
Rectus Sheath
Is a long fibrous sheath
Encloses the rectus abdominis
Formed mainly by aponeurosis of three lateral abdominal muscles
Between the costal margin and the level of the anterosuperior iliac spine, the aponeurosis of the internal oblique splits to enclose the rectus muscle
The external oblique aponeurosis is directed in front of the muscle
Transversus aponeurosis is directed behind the muscle
The posterior wall of the rectus sheath is not attached to the rectus abdominis muscle
The anterior wall is firmly attached to it by the muscle’s tendinous intersections
Linea Alba
The rectus sheath is separated from its fellow on the opposite side by a fibrous band called the linea alba
Extends from the xiphoid process to the symphysis pubis
Anterior Abdominal Wall: Cross Section
58
FASCIA (I): Anatomy
Fascia means ‘band’ in Latin
Fascia is connective tissue (see next slide)
Fascia can be found in every part of the body.
It is located between subcutaneous layer of the skin and the muscles
Non-vascularized - so it heals very slowly
FASCIA (II): Layers
Fascia is divided into 3 key layers.
1. Superficial fascia is attached to the bottom part of the dermis (the recticular dermis) and contains variable amounts of fat. It can stretch in any direction and adjusts quickly to tension, almost like a rubber band.
2. Deep fascia is thin and denser than the superficial fascia. It is also smooth and slippery, which allows the surrounding body parts to glide and slide over each other. This is the type of fascia that is found around muscles, bones, nerves, and vessels.
3. Visceral fascia is the thin, tough membrane that surrounds the viscera or internal organs and keeps them in place.
FASCIA (III): Functions
Fascia seperates tissue layers and provides a sliding/gliding environment for surfaces that need to move or slide along each other.
Fascia keeps things in place. For example: keeping suspending organs in correct orientation
Fascia provides support for blood vessels and nerves through and between muscles
FASCIA (IV): Abdominal Wall
Strongest tissue in the abdominal wall
Anterior and posterior fascia layer.
When discussing midline incisions, “fascia” usually refers to the anterior rectus fascia, the fascia above the rectus muscles. This fascia holds the abdominen together and is the most important layer of closure.
The fascia can extend beyond the muscles and bind to other fascia.
An extension of the fascia is called an aponeurosis.
Midline Abdominal Wall Incision
Midline incisions are made in the midline of the rectus abdominis muscle. The rectus abdominis is actually 2 muscles united by the aponeurosis, which is called the linea alba or “white line.”
Advantages of midline incisions:
1. Safe, as no major vessels nor nerves in the area
2. Faster than transverse incisions
3. Very good access to abdomen
FASCIA: Most Important layer in Closure
The fascia is considered the most important layer in closure of an abdominal surgical wound because it must bear the maximum stress on the incision.
Because of the slow healing time of fascia, immediate and extended wound support is a primary concern.
stress stress
suture in fascia holding
maximum stress on the
incision
Anterior Abdominal Wall Wound complications
&
Factors affecting healing
Goals of fascia closure
Optimal fascial closure – prevent Early and Late Cx
EARLY Cx: Most concern for all Surgeons
- Infection
- Dehiscence
• LATE Cx:
- Incisional Hernia
- Suture Sinus
- Wound Pain
Surgical Site Infection 19 %
Wound dehiscence 4 %
Incisional hernias 16-23 %
Most common complications 123
1. Seiler Ann Surg 2009;249:576-82
2. Bloemen Br J Surg 2011 67
Dehiscence Infection Incisional Hernia
Recent publications show this might be achievable
today
1. Seiler Ann Surg 2009;249:576-82
2. Bloemen Br J Surg 2011
3. Millbourn Arch Surg 2009, RCT 737 patients
68
Surgical Site Infection 19 % < 5 %
Wound dehiscence 4 % < 0,5 %
Incisional hernias 16-23 % < 10 %
Reference:
Millbourn Arch Surg 2009, RCT 737 patients
Strong correlation between complications
1. Israelsson Eur J Surg 1996, van Ramshorst World J Surg 2010
2. van’t Riet Am Surg 2004
3. Bucknall TE Br Med J (Clin Res Ed.) 1982, Fischer JD, Turner FW. Can J Surg 1974
SSI
Incisional
hernia
Wound
dehiscence
Short
term
Long
term
44% of dehiscenced patient
suffer from subsequent
incisional hernia (2)
48% - 88% of patients with
incisional hernia had previously
had an SSI (3)
SSI is an independent risk
factor for both dehiscence and
incisional hernia (1)
Surgical Site infection (I)
Rate: as high as 10-19% reported
• Can extend hosp. stay by 2-11 days
Pathogens : E Coli, Staph. A, Enterococcus
Route of contamination: GI flora, skin flora
Wound infection: independent risk factor for both dehiscence and incisional hernia
Surgical technique :
- normal technique 30-50% of infected patients end up with IH
- small bites- no correlation
- More tissue necrosis with large bites
SSI (II)
• Incidence up to 19% in midline closure, typically > 10% (1)
• Risk factors influenced by wound status
1. Seiler Ann Surg 2009, Justinger Surg 2009, Millbourn Arch Surg 2009
2. Justinger 2009
Example of wound status in 2087 laparotomies in German general surgery department (2)
Wound status n %
Clean 847 41%
Clean contaminated 598 29%
Contaminated 470 23%
Dirty 172 8%
Total 2.087 100%
High impact on patients’ life… and health economics
Surgical Site Infection – A European Perspective of Incidence and Economic Burden David J Leaper, Harry van Goor,
Jacqueline Reilly, Nicola Petrosillo, Heinrich K Geiss, Antonio J Torres, Anne Berger. Int Wound J 2004;1:247—273
High cost of prolonged hospitalisation, medication & additional surgery. €600-8.100 in case of SSI after abdominal surgery1.
Dehiscence (I)
– Rate:0.4% - 3.5 %
– Longer stay and mortality
– Mean: post-op day 9 (Douglas: 0-5 days no strength)
Risk factors (Niggebrugge 1995, van Ramshorst 2010)
Systemic factors: Old age, male gender, malignancy etc.
Local factors:
Layered closure (p<0.001)
post-operative wound infection (p<0.001)
pulmonary complications (p<0.001)
Emergency surgery
Dehiscence (II)
Dehiscence (III)
Local/mechanical factors (more important than systemic factors )
o wound infections
o abdominal distension
o pulmonary complications (Poole GV Jr. Mechanical factors in abdominal wound closure: the prevention of fascial dehiscence. Surgery 1985 Jun;97(6):631-40.)
44% of patients develop incisional hernia after dehiscence (van’t RM et al. Incisional hernia after repair of wound dehiscence: incidence and risk factors. Am Surg 2004 Apr;70(4):281-6)
Adequate tissue breaking strength is necessary to provide support for sutures!
Dehiscence (IV)
IMPLICATIONS:
Prolonged hospital stays
Burst abdomen, exposure of abdominal contents - requires
immediate treatment
Incisional hernia
Re-operations
Increased risk of morbidity and mortality
Dehiscence: Reported causes(1) (V)
1. Poole GV Jr,1985 Jun; 97(6):631-40.) Van Ramshorst et al. Abdominal wound dehiscence in adults. World J
Surg 2010 Jan;34(1):20-7.
2. Poole GV Jr, Surgery 1985 Jun; 97(6):631-40.)
NOTE Can we reduce the risk of cut-through by modifying the suture technique? (2)
Suture related:
Broken suture
Slipping knots
Tissue related:
Suture cutting
through the tissue
• Tissue necrosis
• SSI
Dehiscence : Role of Sutures (VI)
Fascia depends on wound closure device for support during healing!
Patient Movement (bending, jumping, lifting) – increased intra-abd. Pressure > strain on wound and suture
Suture cutting through fascia (± patient factors)
Suture comes UNTIED
Suture Choice: Immediate & extended support
wound edges together
+
Prevent Infection
Incisional hernias (I)
Most common long-time complication after midline incision
Rate 9% - 20% (Seiler CM et al. Interrupted or continuous slowly absorbable sutures for closure of primary elective midline
abdominal incisions. Ann Surg 2009 Apr;249(4):576-582.)
Mechanism
oWound edges separate > 12 mm after 4 weeks
oIncisional hernia develops within weeks after surgery
Playforth MJ et al. The prediction of incisional hernias by radio-opaque markers. Ann R Coll Surg Engl 1986;68:82-
4. PMID: 3954314
Burger JW et al. Incisional hernia: early complication of abdominal surgery. World J Surg. 2005 Dec;29(12):1608-13. PMID: 16311846
Incisional hernias (II): Clinical Studies
Article: The prediction of incisional hernias by radio-opaque markers
Journal: Ann R Coll Surg Engl. 1986 Mar;68(2):82-4
Authors: Playforth MJ, Sauven PD, Evans M, Pollock AV
Abstract: On the hypothesis that incisional defects occur soon after operation but the resulting
hernia may not be diagnosed until months or years later, we attached three to five pairs of stainless steel haemostatic clips to the cut edges of the anterior aponeurosis during the closure of 59 major laparotomy incisions and X-rayed the abdomen one month later. Three patients were withdrawn and the remaining 56 were examined with special reference to incisional herniation at their six-month follow-up visit. The senior author subsequently arranged a series of extra clinics for surviving patients up to three years later (median 30 months after operation). He had no knowledge of the results of the abdominal X-rays when assessing whether or not the patient had a hernia. Six patients were found to have incisional hernias, and correlation with the measurements on the one-month X-rays showed separation of pairs of clips ranging from 12-70 mm (median 40). Three of the six hernias were discovered within seven months, the remaining three at 13, 28 and 29 months. In contrast none of the 50 patients without incisional hernias had more than 9 mm of separation of any pair of clips on the one-month X-ray. We conclude that the origins of incisional hernias can be traced back to events during the first month after operation and that they are not the result of later weakening of a well-healed laparotomy wound.
Incisional hernias (III): Clinical Studies
Article: Incisional hernia: early complication of abdominal surgery
Journal: World J Surg. 2005 Dec;29(12):1608-13
Authors: Burger JW, Lange JF, Halm JA, Kleinrensink GJ, Jeekel H
Abstract: It has been suggested that early development of the incisional hernia is caused by
perioperative factors, such as surgical technique and wound infection. Late development may implicate other factors, such as connective tissue disorders. Our objective was to establish whether incisional hernia develops early after abdominal surgery (i.e., during the first postoperative month). Patients who underwent a midline laparotomy between 1995 and 2001 and had had a computed tomography (CT) scan of the abdomen during the first postoperative month were identified retrospectively. The distance between the two rectus abdominis muscles was measured on these CT scans, after which several parameters were calculated to predict incisional hernia development. Hernia development was established clinically through chart review or, if the chart review was inconclusive, by an outpatient clinic visit. The average and maximum distances between the left and right rectus abdominis muscles were significantly larger in patients with subsequent incisional hernia development than in those without an incisional hernia (P < 0.0001). Altogether, 92% (23/25) of incisional hernia patients had a maximum distance of more than 25 mm compared to only 18% (5/28) of patients without an incisional hernia (P < 0.0001). Incisional hernia occurrence can thus be predicted by measuring the distance between the rectus abdominis muscles on a postoperative CT scan. Although an incisional hernia develops within weeks of surgery, its clinical manifestation may take years. Our results indicate perioperative factors as the main cause of incisional hernias. Therefore, incisional hernia prevention should focus on perioperative factors.
Incisional hernia (IV): Most common long-term complication
Worrying facts:
• Incidence 9 to 25%, even higher for high risk patients
• Risk of obstruction (10%), strangulation (2%)
• Never resolve spontaneously
Recurrence 24% – 58%
Diener Ann Surg 2010 Bloemen Br J Surg 2011, Van’t Riet M, Jeekel J. Br J Surg 2002, 89, 1350-1356
Dubay DA, Franz MG. Surg Clin N Am 83 (2003) 463-481
IH
IH can start developing after 4
weeks after closing!
Incisional hernia (V): Factors
Israelsson Eur J Surg 1997;163:175-80 Murray et al. Am J Surg 2011
Surgical Technique ( x 3 )
Wound Infection ( x 2 )
Overweight
Age
Patient factors
are important.
But technique
above all!
Abdominal Wall Complications & Risk factors summary
Complications
Factors contributing to outcomes:
A. Patient factors Chronic disease, age, overweight etc
B. Tissue factors
Tissue cutting through, necrosis
C. Surgeon factors Broken suture, loose knot
SSI
Incisional
hernia
Wound
dehiscence
Tissue factors
Surgeon factors
Patient factors
Factors contributing to outcomes
Patient factors
Patient factors influence wound healing process Age
Gender
Malnutrition
Systemic Infection
Immunosuppression / Corticosteroids
Underlying disease
Co-morbidities, e.g. diabetes
Hypotension
Overweight
Lifestyle, e.g. smoking
Justinger Surgery 2009
Factors contributing to outcomes
Tissue factors Tissue
factors
Aponeurosis/Fascia: Function is purely mechanical- high proportion of fibres with comparatively little cellularity
Density of blood vessels: most poorly vascularized tissues
Aponeurosis wound repair process: requires considerably more
Rath AM, Chevrel JP. The healing of laparotomies: review of the literature. Hernia 1998;2:145-149
Healing of the abdominal wall FASCIA
Healing of the abdominal wall FASCIA
In an investigation of the healing of lumbodorsal aponeurotic incisions in rabbits, Douglas5 noted that the strength of any of the wounds could not be detected until the sixth day after wounding. All wounds showed measurable strength by the eighth day, and thereafter, a rapid increase until about the end of the second month, when the curve of healing began to flatten out. Subsequently, a slow increase in strength was detectable, which continued throughout the duration of the study (one year). At the end of two weeks, the wound approached 20% of that of unwounded tissue; at the end of one month, 50%; at two months, 60% to 80%; and one-year values, up to 90%
(Douglas DM. The healing of aponeurotic incisions. Br J Surg 1952; 40: 79-84.)
Fascial healing is slow and unpredictable
Rath AM, Chevrel JP. The healing of laparotomies: review of the literature. Part 1. Physiologic and pathologic
aspects. Hernia. 1998;2:145–149.
At 14-28 days, the fascia is
self-supportive but still weak
Even at 2 months, it still has
less than half its original
strength
Fascia Healing: Initial type III collagen is weaker than the definite scar type I
J.J. Hoer etl.al Hernia (2002) 6: 93–98. Dubay and Franz. Surg Clin N Am 83 (2003) 463–481. Hawley PR et al. The
aetiology of colonic anastomosis leaks. Proc R Soc Med. 1970; 63(Suppl 1): 28–30
• Initial phase of wound healing
• Type III (weak) collagen (80%)
• Low tissue tensile strength
• Definite scar
• Type I (strong) collagen (80%)
• High tissue tensile strength
Scar formation regenerative phase
Type I Type III
Extensive inflammation due to i.e. infection leads to
increased break-down of mature collagen and lower
tensile strength of the wound Tensile Strength
Initial wound is totally dependent on suture for strength (I)
Dubay and Franz. Surg Clin N Am 83 (2003) 463–481
Suture strength
needed
Build up of type 1 collagen Time
Lo
ad
Initial wound is totally dependent on suture for strength (II)
Dubay and Franz. Surg Clin N Am 83 (2003) 463–481
Suture strength
needed
Build up of type 1 collagen Time
Load
The wound is at its weakest at post-op day 3
Greenfield’s Surgery, Scientific Principles&Practice, 2001: Chapter 3; Wound Healing:© LIPPINCOTT
WILLIAMS&WILKINS
Lysis
Synthesis
Total collagen
Factors contributing to outcomes
Surgeon factors
Factors under surgeon’s influence
• Antibiotics
• Wound preparation
• Incision location: midline vs.
Transverse
• Suture technique Postop
management: Drainage &
compression
9
6
1. Continuous vs. interrupted
2. Knotting technique
3. Suture length / wound length
ratio
4. Bite size
5. Mass closure vs.
Aponeurosis only
6. Tension
7. Suture material
8. Anti-SSI measures
Midline v/s other incisions Advantages
Easy
no major vessels/nerves in the area
Faster
Excellent access to abdomen
Disadvantages
More pain than transverse or paramedian incisions
Higher rate of incisional hernia
Burger JWA et al. SJS 2002
8 Strategies
to
reduce complications
1 2 3 4 5 6 8 7
No consensus* on technique
12 centers to report closure tactics for primary, elective laparotomies(1)
* >75% of surgeons acting similarly
1. Rahbari et al BMC Surgery 2009
Elective primary
laparotomies
Midline incision 54%
Continuous suture 65%
Interrupted 19%
Combination 15%
Transverse incisions 35%
Other incisions 11%
No consensus* on material
* >75% of surgeons acting similarly 1. Rahbari et al BMC Surgery 2009
12 centers to report closure tactics for primary, elective
laparotomies(1)
Suture type
Monofilament 60%
Braided suture 40%
Suture material
Non-absorbable 5%
Medium term abs
39%
Slowly absorbable
55%
Suture technique
Continuous or interrupted
1 2 3 4 5 6 8 7
Continuous is Easy, faster (half time) & less suture material
Continuous is faster
Accomodates wound lengthening due to distension
Bursting strength of wound signif. higher
Minimizes number of knots-equivalent or lower incidence of incisional hernia
Disadv (theorotical): Wound security depends on singls strand of suture and limited number of knots
Interrupted vs. Continuous technique
Continuous suturing technique
A continuous suture provides:
• More collagen type1
• Higher wound strength
A significantly lower incisional hernia rate (p=0.001)
Markus K. Diener et al. Elective Midline Laparotomy Closure,
Annals of Surgery (2010) vol251, nr 5
Continuous suturing technique
Markus K. Diener et al. Elective Midline Laparotomy Closure,
Annals of Surgery (2010) vol251, nr 5
Continuous suture: Greater tensile strength
Höer et al. Langenbeck’s Arch Surg (2001) 386:218–223
Potential problem: full dehiscence
Continuous suture increases the risk of single point of failure
This can lead to dehiscence (1)
1. Gupta Asian J Surg 2008
Knotting technique
Use self-locking knot
2 3 4 5 6 8 7 1
Good knotting technique
SELF LOCKING KNOT
High knot security
High knot efficiency
Minimal volume
Self-locking knot
Israelsson Eur J Surg 1994;160:323-7 1
0
9
Does not slip
Minimal effect on suture strength
Small in volume
Knot efficiency (1) Knot tensile strength : Straight tensile strength (USP 1 polydioxanone)
1. Israelsson Eur J Surg 1994
Tensile strength %
Straight suture 100%
Conventional knot 58%
Self-locking knot 94%
Suture length / Wound length ratio
SL:WL ratio ≥ 4
1 2 3 4 5 6 8 7
What is the suture length to wound length ratio?
Jenkins Br J Surg 1976
SL:WL ≥4 reduces the rate of incisional hernia (1)
1. Israelsson Eur J Surg 1996;162:605-9
SL:WL ratio Incisional Hernia rate (%)
< 4.0 21%
≥ 4.0 10%
N: 808
SL:WL ≥4 greater tensile strength
Höer et al. Langenbeck’s Arch Surg (2001) 386:218–223
J.J. Höer K. Junge A. Schachtrupp U. Klinge V. Schumpelick Hernia (2002) 6: 93–98
Cengiz Eur J Surg 2000;166:647-9
… and increases the quality and
amount of collagen
SL:WL ≥4 compensates for wound extension
Abdominal distension may lengthen the wound up to 30%!
Jenkins TPN Br J Surg 1976
SL:WL ≥4 compensate for wound extension
SL:WL < 4 SL:WL > 4
✖ ✔
SL:WL<4 may cause necrosis
SL:WL < 4 SL:WL > 4
✖ ✔
Bite size
5-8 mm from wound edges
1 2 3 4 5 6 8 7
SL:WL>4 should be accomplished with small bites
1) Cengiz Arch Surg 2001;136:272-5
Harlaar JJ et al. Small stitches with small suture distances increase laparotomy closure strength. Am J Surg 2009
Sep;198(3):392-5
2) Millbourn Arch Surg 2009
SL:WL ≥4 Small bites 5-8 mm preferable
Higher wound strength(1), lower complication rate(2)
Smaller bites: lower complication rate
Correct placement approximately 5-8 mm from wound edges (1)
Millbourn Arch Surg 2009
Closure technique
1 2 3 4 5 6 8 7
Mass closure or aponeurosis only?
Mass closure v/s layered closure Mass closure: - Incorporate all layers of abd. Wall (except skin) as 1 structure - Statistically significant hernia & dehiscence Layered: - Peritoneum, musculo-aponeurotic layer, skin - incidence adhesions, surgery time, compromises adequacy of subsequent layer closure Bucknall (1982) Prospective study, 1129 abd. Surgeries: significantly higher dehiscence in layered (3.81%) v/s mass closure (0.76%)
Mass closure stitch
Cengiz Eur J Surg 2001;167:60-3
suboptimal
approximation of
the aponeurosis
leads to suture
cutting through
fat and muscle.
Suture cutting through weak tissue
Large bites (>10mm from wound edge), porcine abdominal wall:
1. Harlaar Am J Surg 2009
2. Rath, Chevrel Hernia 1998
Small bites: No separation of wound edges observed(1)
Suture cutting through weak tissue
Large bites (>10mm from wound edge), porcine abdominal wall
1. Harlaar Am J Surg 2009
2. Rath, Chevrel Hernia 1998
Small bites: No separation of wound edges observed(1)
• Sutures first cut through
the relatively weak tissue
lateral to aponeurosis,
causing wound edges to
separate (1)
• This may lead to
developing of an incisional
hernia (2)
Aponeurosis only: Recommended technique
• Good approximation of the edges of aponeurosis
• No separation of wound edges
• No soft tissue necrosis
Tension
1 2 3 4 5 6 8 7
High tension less collagen content lower tensile strength
J.J. Höer K. Junge A. Schachtrupp U. Klinge V. Schumpelick Hernia (2002) 6: 93–98
Höer et al. Langenbeck’s Arch Surg (2001) 386:218–223
Rule of thumb:
The stitches in
aponeurosis
should at least be
visible
Choice of suture material
Absorbable or non-absorbable
1 2 3 4 5 6 8 7
Choice of suture material (I)
Suture material
Non-Absorbable
Braided (Polyester)
Monofilament (Polypropylene,
Nylon)
Absorbable
Medium term
Wound support
3-4 weeks
Braided (Polyglactin 910, Polyglicolid acid)
Monofilament (Polyglecaprone, Glycomer 631)
Long term
Wound support
6 weeks or more
Monofilament
(Polydioxanone, Polyglyconate
Choice of suture material (II)
Suture material
Non-Absorbable
Braided (Polyester)
Monofilament (Polypropylene,
Nylon)
Absorbable
Medium term
Wound support
3-4 weeks
Braided (Polyglactin 910, Polyglicolid acid)
Monofilament (Polyglecaprone, Glycomer 631)
Long term
Wound support
6 weeks or more
Monofilament
(Polydioxanone, Polyglyconate
+ Long term strength
- Risk of sinus
- Patient discomfort and
pain on longer term
Choice of suture material (III)
Suture material
Non-Absorbable
Braided (Polyester)
Monofilament (Polypropylene,
Nylon)
Absorbable
Medium term
Wound support
3-4 weeks
Braided (Polyglactin 910, Polyglicolid acid)
Monofilament (Polyglecaprone, Glycomer 631)
Long term
Wound support
6 weeks or more
Monofilament
(Polydioxanone, Polyglyconate)
Choice of suture material (IV)
Suture material
Non-Absorbable
Braided (Polyester)
Monofilament (Polypropylene,
Nylon)
Absorbable
Medium term
Wound support
3-4 weeks
Braided (Polyglactin 910, Polyglicolid acid)
Monofilament (Polyglecaprone, Glycomer 631)
Long term
Wound support
6 weeks or more
Monofilament
(Polydioxanone, Polyglyconate)
- Long term strength
- Higher risk of Incisional
Hernia
Choice of suture material (V)
Suture material
Non-Absorbable
Braided (Polyester)
Monofilament (Polypropylene,
Nylon)
Absorbable
Medium term
Wound support
3-4 weeks
Braided (Polyglactin 910, Polyglicolid acid)
Monofilament (Polyglecaprone, Glycomer 631)
Long term
Wound support
6 weeks or more
Monofilament
(Polydioxanone, Polyglyconate)
Choice of suture material (VI)
Suture material
Non-Absorbable
Braided (Polyester)
Monofilament (Polypropylene,
Nylon)
Absorbable
Medium term
Wound support
3-4 weeks
Braided (Polyglactin 910, Polyglicolid acid)
Monofilament (Polyglecaprone, Glycomer 631)
Long term
Wound support
6 weeks or more
Monofilament
(Polydioxanone, Polyglyconate)
+ Long term strength
+ No patient discomfort or pain on long term
+ Incisional Hernia risk similar to non-absorbing
sutures
Evidence: Choice of suture material
Absorbable vs. Non-absorbable
Non-absorbable sutures associated to more pain and suture sinuses (1,2)
Equally good results with slowly absorbable sutures
Slowly absorbing vs. Fast absorbing suture
Fast absorbing sutures related to higher rate of incisional hernias (1,3)
Refs: see next page
Evidence: Choice of suture material
Polydioxanone vs. Non-absorbable sutures
Incisional hernia rate after closure with polydioxanone similar to non-absorbable sutures (4,5,6,7)
1. Wissing J et al. Fascia closure after midline laparotomy: results of a randomized trial. Br J Surg 1987 Aug;74(8):738-41. PMID: 3307992
2. van´t Riet M et al. Meta-analysis of techniques for closure of midline abdominal incisions. Br J Surg 2002;89:1350-6. PMID: 12390373
3. Hodgson NC et al. The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg 2000; Mar;231(3):436-42
4. Israelsson LA, Jonsson T. Closure of midlöine laparotomy incisions with polydioxanone and nylon: the importance of suture technique.
Br J Surg 1994;81(11):1606-8. PMID: 7827883
5. Docobo-Durantez F et al. [Randomized clinical study of polydioxanone and nylon sutures for laparotomy clousure in high-risk patients].
Cir Esp. 2006 May;79(5):305-9. PMID: 16753121
6. Hodgson NC et al. The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg 2000; Mar;231(3):436-42
7. Bloemen 2011
Wound support times of different suture materials
Polyglyconate (6wk)
Polyglycolic acid (3wk)
Polyglactin 910 (4wk)
Polydioxanone (10wk)
Wound support times of different suture materials
Impaired wound
Polyglyconate (6wk)
Polyglycolic acid (3wk)
Polyglactin 910 (4wk)
Polydioxanone (10wk)
Anti-bacterial (PLUS) Sutures to prevent SSI
1 2 3 4 5 6 8 7
Multicenter RCT Hygiene measures according to guidelines, correct antibiotic prophylaxis, Monofilament suture
• Despite taking measures, 19% infection rate persists
• Is there a need for additional measures?
Prevention of suture bacterial colonization
• Presence of suture material may increase
the risk of infection (1)
• Bacterial growth on suture material appeared to have the characteristics of biofilm formation(2)
1. Mangram Infect Control Hosp Epidemiol 1999
2. Henry-Stanley et al. Surgical Infections 2010
3. Edmiston et al. J Am Coll Surg 2006
Contamination
Easy to prevend
Biofilm formation
Difficult to treat
Colonization
Prevention of suture bacterial colonization
• Suture with antiseptic provides an effective strategy in reducing perioperative surgical morbidity(3)
1. Mangram Infect Control Hosp Epidemiol 1999
2. Henry-Stanley et al. Surgical Infections 2010
3. Edmiston et al. J Am Coll Surg 2006
Antibacterial sutures are associated with reduced number of infections in abdominal wall closure
Justinger
C et al. Surgery 2009 Prospective
Midline
incision
Significant reduction of wound infections, from
10,8% to 4,9% (2088 patients) (p<0.001)
Ming
malairak J Med Assoc Thai 2009 Randomized
Appen-
dectomy
No difference in
appendectomies (100 patients)
Justinger
C et al.
Langenbecks Arch
Surg 2011 Prospective
Transverse
incision
Significant reduction of wound infections, from 9,2%
to 4,3% (839 patients) (p<0.005)
Rasic Z
et al.
Collegium
Antropologicum 2011 Randomized
Midline
incision
Significant reduction in the wound infection rate
(p=.035) and the dehiscence rate (p=.027)
Galal I, El-
Hindawy K Am J Surg 2011 Randomized
General
surgery
Significant reduction in the
wound infection rate (p=.011)
All publications on antibacterial sutures in abdominal wall closure:
Conclusions (I)
To reduce the complication rates in abdominal midline closure:
(1) Use correct suture technique
• Continuous suture with self-locking knot(s)
• SL:WL ratio > 4
Small stitches at close intervals
• Aponeurosis only
• Minimal tension
• Monofilament, slowly absorbable suture
Conclusions (II)
(2) Prevent wound infections
• Correct suture technique
• Attention to hygiene measures
• Additional measures, e.g. antibacterial sutures
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