EQUINE VETERINARY EDUCATION
Equine vet. Educ. (2019)  () -
doi: 10.1111/eve.13109
Original Article
Clinical and ultrasonographic evaluation of three suture techniques
for closure of the equine linea alba
M. E. Verkade†* , F. Ugahary‡, A. Martens§
†
De Lingehoeve Diergeneeskunde, Lienden, The Netherlands; ‡MD Surgeon n.p., Consultant in General Surgery,
Tiel, The Netherlands; and §Department of Surgery and Anaesthesiology of Domestic Animals, Faculty of
Veterinary Medicine, Ghent University, Merelbeke, Belgium
*Corresponding author email: marliesverkade@hotmail.com
Keywords: horse; closure; linea alba; incisional; suture technique
Summary
Surgical technique plays an important role in preventing
ventral midline incisional complications. The aim of this study
was to compare the clinical and ultrasonographic outcome of
three suture techniques for closure of the linea alba. In this
prospective case series (n = 43), horses operated for acute
abdominal intestinal disease through a midline incision were
randomised in three groups: closure with a conventional
continuous technique (Group 1), a small stitches continuous
technique (Group 2) and the UX-technique (shoe-lace
configuration, Group 3). Age, sex, body weight, type and
duration of surgery were recorded and the suture to wound
length ratio was calculated. Clinical evaluation of the wound
(wound discharge) was performed daily during hospitalisation.
At 7 weeks post-operatively the linea alba was evaluated
clinically and ultrasonographically. The linea alba width was
measured halfway along the length of the incision. One horse
in Group 1 had acute incisional dehiscence, but there were no
further significant differences between the groups in the short
term. Seven weeks post-operatively two horses had complete
herniation in Group 1 and one horse had partial herniation in
Group 2. In the UX group no herniation occurred. The incidence
of herniation was not significantly different between the groups.
On ultrasound at 7 weeks the linea alba width was significantly
smaller in Group 2 (P = 0.00029) and Group 3 (P = 0.0018)
compared with Group 1, even with exclusion of the acute
incisional dehiscence and two herniated horses. Limitations
were the small group size and relatively low incidence of
incisional complications for statistical analysis. It was
concluded that the use of small stitches and the UX-technique
resulted in a smaller linea alba width compared with the
conventional continuous suture technique and might therefore
be preferred for closure of the linea alba in equine colic
surgery.
Introduction
Colic surgery is frequently performed in horses and the ventral
midline incision is the most commonly used surgical
approach. Incisional complications are frequently observed
and include incisional infection, hernia formation and acute
dehiscence (Gibson et al. 1989; French et al. 2002; Mair and
Smith 2005a,c; Isgren et al. 2017). These complications can
be serious and herniation may need surgical re-intervention in
the long term, while acute dehiscence always needs surgical
repair. The incidence of hernia formation after abdominal
surgery in horses has decreased over the last decades, but is
1
and P. Wiemer†§
still up to 10% (Gibson et al. 1989; French et al. 2002; Mair and
Smith 2005a,b,c; Kelmer 2009). Most incisional hernias are
associated with the development of oedema, drainage or
infection in the first week after surgery (Kelmer 2009).
Several risk factors contribute to the development of post-
surgical incisional complications. These include on the one
hand intrinsic factors, such as age, metabolic disorders,
immune status (and disorders), level of pain, body condition
score, and on the other hand extrinsic factors, such as
surgical technique, suture material characteristics and
experience of the surgical team (Humphreys 2009). Whereas
intrinsic factors can only be improved to a certain extent as
they are related to the horse, extrinsic factors can be
optimised by the surgeon. Several studies describe the
importance of suture technique in the prevention of incisional
complications both in humans and horses. The choice of
suture material and suture technique plays an important role
in wound healing by contributing to incisional strength,
preservation of the vascularisation and tension on the wound
edges (Gibson et al. 1989; Israelsson and Jonsson 1993;
French et al. 2002; Kelmer 2009; Auer 2012; Darnaud et al.
2016). Therefore, an optimal closure technique of the linea
alba is important to prevent complications. The
recommended conventional technique after a midline
laparotomy in horses is a continuous pattern with a bite size
and interval size of 1.5 cm (Trostle et al. 1994; Hassan et al.
2006; Ku € mmerle 2012). In human surgery there is evidence
that a continuous closure with smaller stitches reduces the
complication rate and increases the strength of the suture
line (Israelsson and Jonsson 1993; Harlaar et al. 2009; Millbourn
et al. 2011). The described small stitch pattern uses a stitch
interval of 5 mm and incorporates only the linea alba without
passing through the rectus muscle sheath.
Another technique described in human surgery for
abdominal incision closure is the UX-technique (Ugahary 2006).
In this technique, a double continuous suture pattern (the ‘X’) is
supported by a longitudinally placed tape in the medial corner
of the rectus sheath (the ‘U’) to re-inforce the linea alba.
The aim of the present study was to compare the clinical
and ultrasonographic outcome for closure of the equine
linea alba using three different suture techniques: the
conventional continuous technique, the small stitches
continuous technique and the UX-technique. The hypothesis
is that the small stitches continuous technique and the UX-
technique would reduce the risk of incisional herniation and
would result in a smaller linea alba width, compared with the
conventional continuous technique.
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2 Evaluation of three suture techniques for the equine linea alba
Materials and methods
The study was performed between April 2009 and February
2012. Horses that had a midline laparotomy for acute
abdominal intestinal disease were included if owners gave
informed consent for participation to the study. Exclusion
criteria were horses younger than 3 years, a bodyweight
under 500 kg, pregnant mares, horses with a previous
laparotomy and diseases interfering with wound healing (e.g.
pituitary pars intermedia dysfunction, recurrent airway
obstruction, neoplasia, renal disease or liver disease). To
eliminate variations based on individual surgeons, only horses
admitted on days when the same surgeon was on duty were
included. Horses were randomised into three groups just prior
to surgery by picking an envelope. All horses were sedated
with detomidine (Detosedanâ1) (0.01–0.02 mg/kg bwt) and
butorphanol (Dolorexâ2) (0.05–0.1 mg/kg bwt), and received
flunixin meglumine (Finadyneâ2) (1.1 mg/kg bwt) and
gentamicin (Genta-ject 10%â3) (6.6 mg/kg bwt)
intravenously (i.v.) and procaine penicillin (Procapenâ1)
(22.000 IU/kg bwt) intra-muscular (i.m.) prior to surgery.
Anaesthesia was induced with midazolam (Midazolamâ4)
(0.1 mg/kg bwt) and ketamine (Narketan 10â5) (2 mg/kg
bwt) i.v. and the horses were maintained under general
anaesthesia with Isoflurane (IsoFlo 100â6) into a mixture of
oxygen and air. The horses were placed in dorsal
recumbency and the abdomen was clipped, prepared
aseptically and draped in a routine matter. A ventral midline
incision was made through the linea alba starting at the
umbilicus and directing cranially. The length of the incision
was measured with a sterile stainless steel ruler and recorded.
The length of any incisional deviation from the linea alba,
evident by exposed muscle fibres from the rectus abdominis
muscle, was measured in the longitudinal axis with a ruler and
recorded. The surgical procedure was dictated by the acute
abdominal intestinal disease the horse was suffering from and
was performed by the same surgeon for all groups. Closure of
the linea alba was performed using one of the three
techniques described below, depending on the group to
which the horse was assigned. The subcutaneous layer was
closed with a continuous suture pattern using polyglactin 910
USP 0 (Vicryl7) and the skin was closed with polyamide USP 2
(Supramid8) in a continuous interlocking suture pattern. A
sterile cotton stent was sutured on the abdominal wound and
all horses had a head and tail rope-assisted recovery. Most
horses got up at the first or second attempt and were kept in
a standing position with the assistance of the ropes. No
abdominal bandage was applied during recovery or in the
days after. The horses were allowed to lie down in the stable
after surgery. Post-operative care was performed according
to the needs of the horses. The cotton stent remained in
place for 5 days after surgery. It was removed sooner if it
became soaked with wound discharge. All horses received
5 days of i.v. gentamicin (6.6 mg/kg bwt, s.i.d.) and i.m.
procaine penicillin (22.000 IU/kg bwt, b.i.d.) post-operatively.
The horses were box rested with 10 min in hand walking daily
until re-evaluation at 7 weeks post-operatively.
Linea alba suture techniques
Group 1: Conventional continuous technique
In the conventional group, the linea alba was closed
with a bite size of 1.5 cm and an interval of 1.5 cm using a
150-cm long polydioxanone USP 2 (PDS7). The bite size
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and stitch interval were measured with a sterile stainless
steel ruler, to make sure these were uniform throughout the
pattern. The suture was placed in the medial corner of
the external rectus sheath, passing through the external
fascia of the rectus sheath, the rectus abdominis muscle
and the internal fascia of the rectus sheath (Fig 1a). The
end of the suture line was knotted with surgical knots with
5–6 throws.
Group 2: Small stitches continuous technique
A bite size of 6 mm and a bite interval of 6 mm were used in
the small stitches continuous technique group using a 150-cm
long polydioxanone USP 2 (PDS7). The bite size and stitch
interval were measured with a sterile stainless steel ruler, to
make sure these were uniform throughout the pattern. The
stitches were placed in or closer to the linea alba compared
with the conventional technique (Fig 1b). If the suture
material was too short, a second suture strand was used,
starting on the opposite site of the incision. In these cases,
sutures lines were overlapped 2–3 cm in the centre of the
incision and the suture ends were knotted separately with
surgical knots with 5–6 throws.
Group 3: UX-technique
Using the UX-technique, a PDS tape of 5 mm width and
200 cm length (PDS7), was positioned in a U-shaped
configuration in the medial corner of each rectus sheath,
and oversewn using an X-shaped pattern (Fig 1c). To
achieve this UX suture configuration, two tunnelling devices
(custom made9) are required. These tunnelling devices are
slightly curved metal tubes of 40 cm length and a 5 mm
external diameter with a blunt trocar (Fig 2). A small incision
was made in the external fascia of the rectus sheath, 1 cm
lateral to the cranial end of the midline incision. The
tunnelling device was introduced through this small incision
and guided through the medial corner of the rectus sheath
to the caudal end of the midline incision. At the caudal
end of the midline incision the tunnelling device was
exteriorised by making a small incision in the external fascia
over the tip of the tunnelling device. The same was done
at the opposite side of the midline incision. The tape was
divided into two equal parts (but not cut) and suturing was
started at the cranial side of the midline incision. The tape
was placed from left to right in a simple continuous pattern
with a curved Buhner needle with a diameter of 2.5 mm
(custom made9, Fig 2), perpendicular to and just around
the tunnelling device, moving from the cranial edge to the
caudal edge of the incision. The bite size was 1.5 cm from
the wound edge and had a stitch interval of 3 cm. The bite
size and stitch interval were measured with a sterile stainless
steel ruler, to make sure these were uniform throughout the
pattern. After having placed one half of the tape from the
left to the right, the other half of the tape was encircled
around the tunnelling devices from the right to the left in
the same pattern. This created a X-shaped ‘shoe-lace’
configuration, with both ends of the tape at the caudal
end of the incision. At this stage the ends of the tape on
both sides were attached to the trocar in the tunnelling
device and retrieved through the tunnelling device to the
cranial side of the incision. Thereafter, the tunnelling device
was withdrawn from the rectus sheath, leaving the tape in
place. In this way, the longitudinal part of the tape was
positioned in the medial corner of the rectus sheath (U-
M. Verkade et al. 3

a) c) Running tape

ERS

RAM
RAM Longitudinal tape
LA
cranial
IRS

b)

caudal 1 2 3

4 5 6

Fig 1: Schematic presentation and picture of the three suture techniques. The diagrams represent a transverse section of
the abdominal wall with the two rectus sheaths fusing to the linea alba. ERS, external rectus sheath; IRS, internal rectus sheath;
LA, linea alba; RAM, rectus abdominis muscle. a) Conventional continuous technique. b) Small stitch continuous technique.
c) UX-technique (the six steps to obtain the shoe-lace configuration). 1. Introduction of the tunnelling device through a small incision
in the fascia external rectus sheath. 2. Both the tunnelling devices are placed in the medial corner rectus sheath. 3. One side of the
shoe-lace pattern is completed. 4. Both sides of the shoe-lace pattern are completed. 5. Removal of the tunnelling devices from the
medial corner of the rectus sheath, leaving the longitudinal tape in place. 6. Tightening of the shoe-lace pattern. The circle represents
the surgical knot to secure the tape.

shaped), and was encircled by the running part of the
suture (X-shaped). The loose ends of the tape were looped
several times under the running part (2nd or 3rd X) and
attached to it with a polyglactin 910 USP 0 (Vicryl7) surgical
knot with 5–6 throws.
Data recording and measurements
Age, sex, bodyweight, type of surgery (with or without
enterotomy/resection) and duration of surgery were
recorded. The longitudinal length of the linea alba incisional
deviation was recorded in centimetres with a ruler and, if this
occurred at multiple locations, these numbers were added
up to one length. Wound length (WL) was measured with a
ruler for all horses and for Groups 1 and 2 the suture length
(SL) was measured by reducing the total suture length with
the cut ends which were measured with a ruler. The SL:WL
ratio was calculated for Groups 1 and 2. Acute dehiscence
was defined as the failure of the abdominal wall closure with
protrusion of the abdominal contents and was acted upon
immediately, by re-operating if possible. Clinical evaluation of
the wound for signs of infection was performed daily during
hospitalisation. Infection was defined as any purulent
discharge from the incision 48 h post-operatively and of more
than 36 h of duration. Seven weeks after surgery, the wound
was evaluated clinically for herniation, which was defined as
a palpable or visible defect in the abdominal wall with
overlying intact skin. Ultrasonography of the linea alba was
performed 7 weeks after surgery (Aloka 3500, linear probe 5–

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4 Evaluation of three suture techniques for the equine linea alba
1.
2.
3.
Fig 2: Custom-made tunnelling device and Buhner needle.
1. Slightly curved tunnelling device with trocar inserted, tip is
displayed to the left. 2. Slightly curved tunnelling device and
trocar separate, tip is displayed to the left. 3. Curved Buhner
needle, needle tip is displayed to the left.
10 MHz10). The incisional area was cleaned, clipped and
alcohol was applied to retrieve the best image. The area of
interest was halfway along the length of the incision, and this
was determined with a tape measure. Transverse images of
the linea alba were obtained and the width of the linea alba
was measured by measuring the distance between the
medial corners of the rectus abdominis muscle. All
measurements were done using an automatic ruler. Standard
machine settings for tendons were used and the frequency,
focus and depth were adjusted to individual horse and area
of interest.
Statistical analysis
Relationships between suture techniques and the recorded
variables (age, sex, bodyweight, type of surgery, length of
incisional deviation, length of incision, surgical site infection,
width of the linea alba 7 weeks post-surgery, occurrence of
herniation and duration of hospitalisation) were explored. For
continuous variables, differences between suture techniques
were analysed using ANOVA. Normality of residuals was
evaluated on QQ plots and by Shapiro-Wilk tests.
Homogeneity of variances was evaluated on residuals VS
fitted plots and by a Levene’s test. When residuals were not
normally distributed, a Kruskal-Wallis test was performed
instead. When heteroscedasticity was detected, the data
were analysed using a Welch test with Games-Howell post-
hoc test. For discrete variables, differences between suture
techniques were analysed using chi square tests, except
when occurrences of an event were low, in which case a
Firth regression was used. Significance was set at P<0.05
(SPSS 25 for Windows11).
Results
Seventy-three horses were initially included in the study: 11
were subjected to euthanasia during surgery, 10 were
subjected to euthanasia within a week after surgery for other
reasons than wound complications and 9 were lost during the
follow-up period. Data were retrieved from the remaining 43
horses and are presented in Table 1. Results were obtained
for 14 horses in both Groups 1 and 2 and for 15 horses in
Group 3. The results are reported as mean  s.d.
There was no significant difference in age, sex,
bodyweight, type of surgery, length of incision, duration of
© 2019 EVJ Ltd
surgery and duration of hospitalisation between the three
different groups.
The mean length of the linea alba incisional deviation
was greater in Group 3 than in Groups 1 and 2, although not
significantly (3.0 cm  0.76 cm in Group 3, 1.64 cm 
0.47 cm (P = 0.414) and 1.5 cm  0.62 cm (P = 0.306) in
Groups 1 and 2 respectively). Any deviation from the linea
alba always occurred in the cranial part of the incision.
The mean incision length (in cm) did not differ significantly
between groups (19.5 cm  1.2 cm in Group 1, 19.9 cm 
1.4 cm in Group 2 and 22.3 cm  1.1 cm in Group 3). The
conventional technique had a SL:WL ratio of 4.5:1, while the
ratio in the small stitch group was 5.6:1.
One horse in Group 3 developed a surgical site infection
48 h after surgery and still present 96 h post-operatively. There
were no horses in the other groups with signs of surgical site
infection as previously defined. This difference between the
groups was not significant. There was no prolonged
antimicrobial treatment or additional wound drainage
necessary during this period of time. The skin sutures were
removed 14 days post-operatively, at which time no wound
drainage was encountered in either groups. In Group 1, there
was one horse with an acute dehiscence during recovery
from anaesthesia, because of a rupture of the suture at 2/3
of the incision length. This horse was re-operated and
excluded from the ultrasonographic evaluation at 7 weeks.
Clinical evaluation 7 weeks post-operatively showed two
horses in Group 1 with a complete herniation. In Group 2 one
horse showed a herniation of the cranial third of the incision.
In Group 3 no herniation occurred. This difference was not
significant between the groups (Group 2; P = 0.321, Group 3;
P = 0.079 compared with Group 1). On ultrasonographic
evaluation 7 weeks post-operatively (Fig 3) the width of the
linea alba was significantly smaller in Groups 2 and 3
compared with Group 1 (6.0  1.0 cm in Group 1, with
exclusion of the acute burst and two herniated horse;
2.5  0.3 cm (P = 0.012) in Group 2 and 3.0  0.1 cm
(P = 0.03) in Group 3) (Fig 4).
Discussion
Despite extensive research into intrinsic risk factors, different
suture materials and methods to protect the incision after
surgery, the incidence of incisional complications after
ventral midline celiotomy is still high (Fogle 2019). Human
literature states that up to 70% of incisional complications can
actually be linked to extrinsic risk factors like the experience
of the surgical team and the surgical technique used
(Israelsson 1998; Humphreys 2009). This finding urges the
necessity to investigate the outcome of different surgical
techniques to prevent incisional complications in equine
horses. To the authors’ knowledge, this is the first prospective
study comparing different suture techniques for closure of the
linea alba in clinical equine horses.
The incidence of herniation in this study (9.3%) is in
agreement to previous studies (Trostle et al. 1994; French
et al. 2002). Although the numbers are small and there was
no significant difference, the occurrence of one acute
dehiscence and two herniations in Group 1 suggests that the
conventional technique might be the weakest of the three
suture techniques in this study. In these three horses no
surgical site infection was present. The USP 2 suture material
that was used is relatively small for the over 500 kg horses that
M. Verkade et al. 5

TABLE 1: Horse and surgical data for the 43 horses where follow-up after surgery was available

Group 1 Group 2 Group 3

Conventional Small stitch UX-technique
N = 14 N = 14 N = 15

Pre-operative Mean age (years + range) 11.6 (4–30) 10.6 (3–22) 8.7 (3–20)
Mean bodyweight (kg + range) 569 (510–628) 576 (506–620) 580 (504–698)
Sex (N)
Stallion 1 3 1
Gelding 6 5 7
Mare 7 6 7
Breed (N)
Warmblood 11 11 12
Friesian 1 1 2
Other 2 2 1
Peri-operative Mean incision length (cm  s.d.) 19.5  1.2 19.9  1.4 22.3  1.1
Mean length deviation LA (cm  s.d.) 1.64  0.47 1.5  0.62 3.0  0.76
Type of surgery (N)
Enterotomy/resection 6 8 7
No enterotomy/resection 8 6 8
Duration of surgery (min  s.d.) 80  5.5 94  5.5 91  6.2
SL:WL ratio 4.5:1 5.6:1 -
Hospitalisation Clinical signs (N)
Surgical site infection 0 0 1
Acute dehiscence 1 0 0
Days of hospitalisation (mean + range) 7.8 (5–18) 7.7 (5–14) 7.3 (5–14)
7 weeks post-operative Incidence herniation (N) 2 1 0
Width of LA (cm + s.d.) 6.0  1.0* 2.5  0.3 3.0  0.1

* Significant (P < 0.05).

RAM RAM RAM

RAM
LA
LA

a) c)

RAM
RAM
RAM RAM

LA
LA
b) d)

Fig 3: Ultrasonographic evaluation of the linea alba 7 weeks post-operatively. Transverse image of the linea alba obtained with a
linear ultrasound probe. LA, linea alba; RAM, rectus abdominis muscle. a) Normal LA (non operated = reference image). b) LA after
conventional closure (Group 1). c) LA after small stitch closure (Group 2). d) LA after UX-closure (Group 3). The longitudinal PDS tape
(arrows) in the rectus sheath as well as the running PDS tape (asterisk) are still visible.

were included in the study. A larger suture material size could
potentially improve the results, especially for the conventional
technique. The small stitches technique in Group 2 could
apparently compensate for the smaller sized suture material,
since complete incisional herniations did not occur. A larger
size suture material, in combination with the small stitch
technique could be even more resistant to hernia formation.
As the linea alba becomes smaller in width when it
advances cranially, incisional deviation is more likely to
happen in the cranial part of the incision, which was also the
case in the present study (Trostle et al. 1994). Deviation from
the linea alba and opening of the rectus sheath impairs the
suture strength, because the holding power of the external
fascia of the rectus sheath is less than the holding power of
the linea alba (Boone et al. 2014). Not only the fibrous mass
contributes to this holding power, but also the alignment of
the fibres (Axer et al. 2001; Levillain et al. 2016). In the
external fascia of the rectus sheath the collagen fibre pattern
is orientated predominantly in a craniolateral-caudomedial
oblique pattern. The internal fascia of the rectus sheath

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6 Evaluation of three suture techniques for the equine linea alba
10
8 ex vivo study showing that equine linea alba closed with the
Width of LA (cm)
6 Ugahary 2008). From a technical point of view, the UX-
4
* et al. 2007; Wiemer and Ugahary 2008). The technique
*
2
0
Conventional Small stitch UX
Suture technique
Fig 4: Width of the linea alba 7 weeks post-operatively in the three
groups. Bar graph representing the mean values for the width of the
linea alba at 7 weeks post-operatively. The error bars represent the
standard deviation. The asterisk represents a significant difference
compared with the conventional technique. (P<0.05).
mainly has fibre patterns in a transverse direction. In the linea
alba, where the fascia of both external and internal rectus
sheaths join, the fibre directions from both sides are
continued, resulting in a complex crossing pattern of fibres. As
a result, the suture cannot cut through the linea alba as
easily as compared with the fascia of the rectus sheath (Axer
et al. 2001; Boone et al. 2014; Levillain et al. 2016). In the
conventional suture technique, the stitches are placed lateral
to the linea alba through the rectus sheath. Because of the
tensile forces the suture is pulled through the external fascia
of the rectus sheath until it reaches the lateral border of the
linea alba (Wiemer and Ugahary 2008). This could have
contributed to the pronounced widening of the scar of the
linea alba which was observed ultrasonographically 7 weeks
post-operatively. With this tearing, additional tissue trauma
occurs, leading to disturbances in vascularisation and
possible inflammation which may result in delayed healing
and an increase in complications (Kelmer 2009). Several
surgical aspects, like surgical time, type of surgery and
incision length have previously been described as risk factors
for incisional complications (Wilson et al. 1995; Honnas and
Cohen 1997; Colbath et al. 2014; Darnaud et al. 2016). In our
study, these risk factors did not appear to be significantly
different between the groups.
There is limited data available on suture bite intervals in a
simple continuous suture pattern for the equine linea alba.
Trostle et al. (1994) suggested an ideal suture interval and bite
size of 1.5 cm. Hassan et al. (2006) then investigated a smaller
suture interval with the same bite size and did not find any
significant differences in bursting strength, compared with the
1.5 cm interval and bite size. Both these studies only
investigated the strength of the linea alba in cadaver tissue by
tensile forces in a transverse direction, with one single failure
load. This does not represent a clinical situation where the
linea alba shows an anisotropic behaviour and is exposed to
multi-directional tension and repetitive loading (Cooney et al.
2015, 2016). Further research on clinical horses is needed to
find the ideal suture interval and bite size.
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The choice for including the UX-technique in the
comparison was based on the promising results obtained in
human medicine (Ugahary 2006) and on the results of an
UX-technique had a significantly higher tensile strength
compared with the conventional suture pattern (Wiemer and
technique is superior in terms of tension distribution, because
the longitudinal part of the tape reinforces the linea alba by
distributing the tension on the linea alba equally (Hollinsky
however has some potential downsides in equine horses.
There is a higher amount of suture material needed to
complete the UX-technique, but no knots are made with the
tape to prevent bulking of the suture material. Although no
surgical site infections occurred in this study, there could be a
risk of the tape forming a nidus and becoming infected. To
reduce the risk of infection, it is preferable to place the tape
in a flat configuration to avoid pocket formation by twisting
of the tape. Compared with a standard continuous pattern,
the UX-technique is more challenging to perform. Therefore,
the authors do not use this technique routinely, but it is
considered in horses with an increased risk for herniation.
Further research should be done to investigate the possibility
of using a combination of different suture materials with this
technique (e.g. tape for longitudinal part, normal suture
material for running part).
The incidence of surgical site infections in this study (2%) is
lower than the 10–37% previously described (Fogle 2019). This
could partially be related to the fact that the cotton stent
stayed in place for 5 days post-operatively. The outcome of
using a stent as preventative for incisional complications
varies widely in the literature (Gibson et al. 1989; Mair and
Smith 2005a,c; Torfs et al. 2010; Tnibar et al. 2013). Although
the incision was checked daily for drainage and the stent
was removed when it became soaked with discharge, the
stent could have contributed to missing horses with mild
incisional discharge. At the time of suture removal 14 days
post-operatively, none of the horses showed signs of either
surgical site infection or incisional drainage.
Ultrasonography is a useful diagnostic tool to evaluate the
linea alba (Mendes et al. 2007; Beer et al. 2009; Verkade
et al. 2018). At ultrasonographic evaluation 7 weeks post-
operatively, both the small stitch and the UX-technique had
significantly less widening of the linea alba. This is probably
due to a stronger suture-wound interface, with less tearing of
the suture, resulting in reduction of vascular compromise and
inflammation. The UX-technique showed a slightly wider linea
alba scar compared with the small stitch technique, which
could be explained by the fact that the Buhner needle is not
so curved that it could follow the radius of the tunnelling
device. Because of that, the running tape is not entirely
tightly apposing the longitudinal part of the tape. In the small
stitch technique, the stitches are placed in or just beside the
linea alba with a narrow stitch interval. The tensile forces are
distributed onto more stitches (5 stitches/3 cm vs.  1.8
stitches/3 cm for a conventional suture pattern), resulting in
less tearing at the wound edges. The small stitches technique
achieved a good outcome even with the small suture
material size (USP 2) used in this study. This finding suggests
that with the smaller stitch interval technique the suture
material size could potentially be down-sized from the
conventional used material (USP5-7), thereby contributing to
M. Verkade et al.
the reduction of the infection rate at the suture material
(Marshall and Blikslager 2019).
Objective data concerning the quality of the fibrous scar
tissue could not be obtained due to the design of the study
and the small group sizes and the relatively low incidence of
incisional infection were other important study limitations.
Conclusion
Although the numbers are relatively small, the present study
indicates that both the small stitch technique and the UX-
technique resulted in a significantly smaller linea alba scar
compared with the conventional continuous suture technique
and might be preferred for closure of the linea alba in equine
colic surgery.
Authors’ declaration of interests
No conflicts of interest have been declared.
Ethical animal research
The authors confirm that Dutch law allows randomised
prospective research studies on clinical horses with existing
techniques to proceed without oversight from an Ethical Review
Committee.
Sources of funding
No funding received.
Acknowledgements
We thank Dr M. Haspeslagh for his assistance with statistical
consulting and H. Tremaine for proof-reading the manuscript.
Authorship
M. Verkade and P. Wiemer contributed to study design, study
execution, data analysis and interpretation, and preparation
of the manuscript. F. Ugahary contributed to study design
and study execution. A. Martens contributed to preparation
of the manuscript. All authors gave their final approval of the
manuscript.
Manufacturers' addresses
1
AST Farma, Oudewater, the Netherlands.
2
MSD Animal Health Nederland, Boxmeer, the Netherlands.
3
Dopharma, Raamsdonksveer, the Netherlands.
4
Actavis, Baarn, the Netherlands.
5
Vetoquinol, ’s Hertogenbosch, the Netherlands.
6
Zoetis, Capelle a/d IJssel, the Netherlands.
7
Ethicon, Norderstedt, Germany.
8
B Braun Medical, Melsungen, Germany.
9
Knijpers instruments, Groesbeek, The Netherlands.
10
Aloka Co. Ltd., Tokyo, Japan.
11
IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version
25.0., Armonk, NY.
References
Auer, J.A. (2012) Chapter 12 - surgical techniques. Equine Surgery, 4th
edn., W.B. Saunders, St Louis. pp 138-149.
Axer, H., Keyserlingk, D.G. and Prescher, A. (2001) Collagen fibers in
linea alba and rectus sheaths. J. Surg. Res. 96, 127-134.
7
Beer, G.M., Schuster, A., Seifert, B., Manestar, M., Mihic-Probst, D. and
Weber, S.A. (2009) The normal width of the linea alba in nulliparous
women. Clin. Anat. 22, 706-711.
Boone, L.H., Epstein, K., Cremer, J., Rogers, A., Foutz, T., Quandt, J. and
Mueller, P.O.E. (2014) Comparison of tensile strength and early
healing of acute repeat celiotomy through a ventral median or a
right ventral paramedian approach. Vet. Surg. 43, 741-749.
Colbath, A.C., Patipa, L., Berghaus, R.D. and Parks, A.H. (2014) The
influence of suture pattern on the incidence of incisional drainage
following exploratory laparotomy. Equine Vet. J. 46, 156-160.
Cooney, G.M., Moerman, K.M., Takaza, M., Winter, D.C. and Simms,
C.K. (2015) Uniaxial and biaxial mechanical properties of porcine
linea alba. J. Mech. Behav. Biomed. Mater. 41, 68-82.
Cooney, G.M., Lake, S.P., Thompson, D.M., Castile, R.M., Winter, D.C.
and Simms, C.K. (2016) Uniaxial and biaxial tensile stress-stretch
response of human linea alba. J. Mech. Behav. Biomed. Mater. 63,
134-140.
Darnaud, S.J.M., Southwood, L.L., Aceto, H.W., Stefanovski, D.,
Tomassone, L. and Zarucco, L. (2016) Are horse age and incision
length associated with surgical site infection following equine colic
surgery? Vet. J. 217, 3-7.
Fogle, C.. (2019) Chapter 41 - postoperative care, complications, and
reoperation of the colic patient. In: Equine Surgery, 5th edn., Eds:
Auer, J.A., Stick, J.A., Ku € mmerle, J.M. and Prange, T., W.B.
Saunders, Philadelphia. pp 660-677.
French, N.P., Smith, J., Edwards, G.B. and Proudman, C.J. (2002)
Equine surgical colic: risk factors for postoperative complications.
Equine Vet. J. 34, 444-449.
Gibson, K.T., Curtis, C.R., Turner, A.S., McIlwraith, C.W., Aanes, W.A.
and Stashak, T.S. (1989) Incisional hernias in the horse incidence
and predisposing factors. Vet. Surg. 18, 360-366.
Harlaar, J.J., van Ramshorst, G.H., Nieuwenhuizen, J., ten Brinke, J.G.,
Hop, W.C.J., Kleinrensink, G. and Lange, J.F. (2009) Small stitches
with small suture distances increase laparotomy closure strength.
Am. J. Surg. 198, 392-395.
Hassan, K.A., Galuppo, L.D. and van Hoogmoed, L.M. (2006) An in vitro
comparison of two suture intervals using braided absorbable loop
suture in the equine linea alba. Vet. Surg. 35, 310-314.
Hollinsky, C., Sandberg, S. and Kocijan, R. (2007) Preliminary results with
the reinforced tension line: a new technique for patients with
ventral abdominal wall hernias. Am. J. Surg. 194, 234-239.
Honnas, C.M. and Cohen, N.D. (1997) Risk factors for wound infection
following celiotomy in horses. J. Am. Vet. Med. Assoc. 210, 78-81.
Humphreys, H. (2009) Preventing surgical site infection. where now? J.
Hosp. Infect. 7, 316-322.
Isgren, C.M., Salem, S.E., Archer, D.C., Worsman, F.C.F. and Townsend,
N.B. (2017) Risk factors for surgical site infection following
laparotomy: effect of season and perioperative variables and
reporting of bacterial isolates in 287 horses. Equine Vet. J. 49, 39-44.
Israelsson, L.A. (1998) The surgeon as a risk factor for complications of
midline incisions. Eur. J. Surg. 164, 353-359.
Israelsson, L.A. and Jonsson, T. (1993) Suture length to wound length
ratio and healing of midline laparotomy incisions. Br. J. Surg. 80,
1284-1286.
Kelmer, G. (2009) Update on recent advances in equine abdominal
surgery. Vet. Clin. N. Am: Equine Pract. 25, 271-282.
€ mmerle, J.M.. (2012) Chapter 16 - suture materials and patterns. In:
Ku
Equine Surgery, 4th edn., Eds: Auer, J.A. and Stick, J.A., W.B.
Saunders, St. Louis. pp. 181-202.
Levillain, A., Orhant, M., Turquier, F. and Hoc, T. (2016) Contribution of
collagen and elastin fibers to the mechanical behavior of an
abdominal connective tissue. J. Mech. Behav. Biomed. Mater. 61,
308-317.
Mair, T.S. and Smith, L.J. (2005a) Survival and complication rates in 300
horses undergoing surgical treatment of colic. part 2: short-term
complications. Equine Vet. J. 37, 303-309.
Mair, T.S. and Smith, L.J. (2005b) Survival and complication rates in 300
horses undergoing surgical treatment of colic. part 1: short-term
survival following a single laparotomy. Equine Vet. J. 37, 296-302.
© 2019 EVJ Ltd
8 Evaluation of three suture techniques for the equine linea alba
Mair, T.S. and Smith, L.J. (2005c) Survival and complication rates in 300
horses undergoing surgical treatment of colic. part 3: long-term
complications and survival. Equine Vet. J. 37, 310-314.
Marshall, J.F. and Blikslager, A.T.. (2019) Chapter 33 - colic: diagnosis,
surgical decision, preoperative management and surgical
approaches to the abdomen. In: Surgery, Equine 5th edn., Eds:
Auer, J.A., Stick, J.A., Ku € mmerle, J.M. and Prange, T., Saunders,
Philadelphia. pp 521-528.
Mendes, D.D.A., Nahas, X., Veiga, D.F., Mendes, F.V., Figueiras, R.,
Gomes, H.C., Ely, P.B., Novo, N.F. and Ferreira, L.M. (2007)
Ultrasonography for measuring rectus abdominis muscles diastasis.
Acta Cir. Bras. 22, 182-186.
Millbourn, D., Cengiz, Y. and Israelsson, L.A. (2011) Risk factors for
wound complications in midline abdominal incisions related to the
size of stitches. Hernia 15, 261-266.
Tnibar, A., Grubbe Lin, K., Thurøe Nielsen, K., Christophersen, M.T.,
Lindegaard, C., Martinussen, T. and Ekstrøm, C.T. (2013) Effect of a
stent bandage on the likelihood of incisional infection following
exploratory coeliotomy for colic in horses: a comparative
retrospective study. Equine Vet. J. 45, 564-569.
© 2019 EVJ Ltd
Torfs, S., Levet, T., Delesalle, C., Dewulf, J., Vlaminck, L., Pille, F. and
Martens, A. (2010) Risk factors for incisional complications after
exploratory celiotomy in horses: do skin staples increase the risk?
Vet. Surg. 39, 616-620.
Trostle, S.S., Wilson, D.G., Stone, W.C. and Markel, M.D. (1994) A study
of the biomechanical properties of the adult equine linea alba:
relationship of tissue bite size and suture material to breaking
strength. Vet. Surg. 23, 435-441.
Ugahary, F.. (2006) New suture technique midline abdominal incision.
Proc. Asian Pacific Hernia Congress, New Delhi.
Verkade, M.E., Hepburn, R., Wiemer, P. and Suthers, J. (2018)
Ultrasonographic evaluation of the normal equine linea alba.
Veterinary Surgery Scientific Presentation Abstracts European
College Veterinary Surgeons Annual Scientific Meeting 47, E18.
https://doi.org/10.1111/vsu.12910
Wiemer, P. and Ugahary, F. (2008) UX closure of the linea alba; acute
bursting strength study in fresh equine cadavers and preliminary
clinical results. Proceedings European Hernia Society, Sevilla, 183.
Wilson, D.A., Baker, G.J. and Boero, M.J. (1995) Complications of
celiotomy incisions in horses. Vet. Surg. 24, 506-514.