Wound Closure Technique and Acute Wound Complication in Gastric Surgery for Morbid Obesity

Dezie AJ, Silvestri F, Liriano E, Benotti P American College of Surgeons, September 2000

Journal Club Department of Surgery Prince of Wales Hospital

Study Design
Prospective, randomized study of midline fascial closure technique in gastric bariatric patient Conducted between 1991-1998 331 consecutive morbidly obese patients 2 groups randomized:
Group 1: Continuous fascial closure (n=172) Group 2: Interrupted fascial closure (n=159)

Study Design
Patients randomized intraoperatively by odd/even MRN at time of fascial closure Randomized suture material (Nylon vs PDS) 4 different surgeons performing surgery Wounds monitored for 30 days post-op End points
superficial wound complications (superficial infections, seromas and haematomas) Deep wound complications (deep surgical infections and fascial dehiscence)

Fascial Closure Technique

Table 1

Conclusions
No significant differences between techniques in incidences of superficial complications Continuous fascial closure were associated with fewer deep complications Similar outcomes were observed with both monofilament suture materials Continuous fascial closure reduces major acute wound complications in morbidly obese patients undergoing gastric operations

 Strengths
Reasonable patient numbers Prospective randomized trial Comparing surgical technique and suture material Clear endpoints

Weakness
Inclusion criteria not stately clearly Randomization method (not double blinded) Ordered categories to show adequacy of randomization technique (patient factors, co-morbidities) Identification of complications by surgeons (bias) Data collection ?independent source

Meta-analysis of techniques for closure of midline abdominal incisions

Date of Most Recent Update: 2004 NHS Centre for Reviews and Dissemination. University of York, York, U.K. Abstract and Commentary for: van't Riet M, Steyerberg E W, Nellensteyn J, Bonjer H J, Jeekel J. Meta-analysis of techniques for closure of midline abdominal incisions. British Journal of Surgery. 2002; 89(11):1350-1356. 15 studies reviewed (6566 patients)

Results of the Review

Continuous closure using rapidly absorbable versus nonabsorbable sutures (1 RCT, n=751): rapidly absorbable sutures resulted in significantly more incisional hernias (P=0.001), but less suture sinuses (P<0.001) and prolonged wound pain (P=0.003) NO statistically-significant difference between the two suture types for any other outcome measure. Continuous closure using slowly absorbable versus nonabsorbable sutures (5 RCTs, n=2,669): non-absorbable sutures resulted in significantly more wound pain (P<0.005) and suture sinuses (P<0.02) NO statistically-significant difference between the two types for the incidence of hernias, wound dehiscence or infection.

Results of the Review

Interrupted rapidly absorbable versus continuous slowly absorbable (4 RCTs, n=1,992): there was no statistically- significant difference between the groups for any of the outcome measures
Interrupted non-absorbable versus continuous rapidly absorbable (1 RCT, n=105): there was no statisticallysignificant difference between the groups for the incidence of hernias, wound dehiscence, or wound infection

Results of the Review

Continuous versus interrupted (any suture type): the pooled analysis did NOT show any significant difference between the two techniques for incisional hernias (odds ratio 0.9, 95% confidence interval: 0.6, 1.2, P=0.40), or the incidence of wound dehiscence or wound infection (no results presented).
Analysis of the suture length to wound length ratio (3 RCTs): two studies reported that an increased suture length to wound length ratio of 4:1 or even 6:1 resulted in a significant decrease in the incidence of incisional hernia.

Author's conclusions
To reduce the incidence of incisional hernia without increasing wound pain or suture sinus frequency, slowly absorbable continuous sutures appear to be the optimal method of fascial closure.
Adequate suture length (suture length to wound length ratio of at least 4:1)