• Users Online: 185
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 14  |  Issue : 2  |  Page : 59-66

Rate of development of incisional hernia 1 year after urgent midline laparotomy


Department of General Surgery, Faculty of Medicine, Aswan University, Aswan, Egypt

Date of Submission17-Feb-2016
Date of Acceptance02-May-2016
Date of Web Publication21-Oct-2016

Correspondence Address:
Abd-El-Aal A Saleem
Department of General Surgery, Faculty of Medicine, Aswan University, Aswan
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-1693.192653

Rights and Permissions
  Abstract 

Objective
The aim of the present study was to determine the rate of development of incisional hernia at 6 months and 1 year in patients suffering from peritonitis (potentially septic wounds) and other patients suffering from intraperitoneal hemorrhage (IPHge) (aseptic wounds) who had undergone urgent midline laparotomy. In addition, we aimed to evaluate different surgical techniques and suture materials used for abdominal closure and the prevalence of postoperative complications among the studied groups in the Emergency Department of Aswan University Hospital, Egypt.
Patients and methods
This observational and descriptive study included evaluation and assessment of interviews of 160 patients divided into two groups (A and B). Group A included 80 patients suffering from peritonitis and group B included 80 patients suffering from IPHge. All patients submitted to the surgical treatment in the form of emergency exploratory laparotomy and evaluation of their medical records, involving different surgical techniques and suture materials used for abdominal closure. Postoperative follow-up was set at 6 months and 1 year for the development of incisional hernia.
Results
Analyses of 160 patients in the two groups indicated that the incisional hernia rate increased significantly from 7.5% at 6 months to 17.5% at 1 year after urgent midline laparotomy in all studied patients (P=0.007). There was a significant increase in incisional hernia rate in group A in comparison with group B at 6 months (12.5 vs. 2.5%; P=0.02) and at 1 year (25 vs. 10%; P=0.01) follow-up after urgent midline laparotomy. Regarding the techniques of closure of urgent midline laparotomy and the used suture materials (Vicryl and Prolene), there was an insignificant deference as regards the development of incisional hernia between subgroups A1 and A2 at 6 months (P=0.50) and at 1 year (P=0.30), and also between subgroups B1 and B2 at 6 months (P=0.49) and at 1 year (P=1.0) follow-up after urgent midline laparotomy.
Conclusion
The incisional hernia remains the most common complication after midline laparotomy, representing 7.5% at 6 months and 17.5% at 1 year follow-up in the present study. Incisional hernia was significantly increased in patients suffering from peritonitis than in those patients suffering from IPHge at 6 months and at 1 year after urgent midline laparotomy. Regarding the surgical techniques and suture materials used for closure of urgent midline laparotomy, there was an insignificant difference as regards the development of incisional hernia between closure of urgent midline incision by continuous suture plus some interrupted sutures in between using slowly absorbable multifilamentous suture material [Vicryl (polyglactin)] and continuous suture only using nonabsorbable monofilamentous suture material [Prolene (polypropylene)] at 6 months and 1 year between subgroups A1 and A2, and between B1 and B2.

Keywords: emergency laparotomy, incisional hernia, rate


How to cite this article:
Saleem AEA, Abdallah HA, Abdul Raheem OA, Yousef MA. Rate of development of incisional hernia 1 year after urgent midline laparotomy. Al-Azhar Assiut Med J 2016;14:59-66

How to cite this URL:
Saleem AEA, Abdallah HA, Abdul Raheem OA, Yousef MA. Rate of development of incisional hernia 1 year after urgent midline laparotomy. Al-Azhar Assiut Med J [serial online] 2016 [cited 2017 Oct 17];14:59-66. Available from: http://www.azmj.eg.net/text.asp?2016/14/2/59/192653


  Introduction Top


Incisional hernia is the most frequent postoperative complication following general surgery. The cumulative incidence has remained constant despite several attempts to improve laparotomy closure. In addition to the surgical closure technique, individual biological and patient-dependent risk factors play a key role [1]. Incisional hernia remains the most frequent long-term complication in visceral surgery after midline laparotomy, often requiring reoperation for repairing. The rate 1 year after laparotomy is within the range of 9–20% [2]. The rate of incisional hernia increased significantly from 12.6% at 1 year to 22.4% at 3 years after midline laparotomy [3]. The cause of incisional hernia is multifactorial and influenced by patient-related and technical factors. Patient-related factors include obesity, malignancy, wound infection, diabetes mellitus (DM), use of immunosuppressant agents, corticosteroids, smoking, and previous laparotomy and cannot be influenced by the surgeon. Technical factors, however, are directly controllable and amenable to action by the surgeon. Attempts to minimize hernia rates after laparotomy have led to various surgical options − variations of incision type, closure technique, and suture material [3]. There is high incidence of incisional hernia following operations for peritonitis because, as a rule, the wound becomes infected. The placing of a drainage tube through a separate stab incision as opposed to bringing such a tube through the laparotomy wound reduce the frequency of incisional hernia [4]. Incisional hernia can occur at sites of defective healing within the approximating incision or at the suture puncture sites created during the closure, or both. Repair of incisional hernias can be technically challenging, and a myriad of methods have been described. The most important distinctions in describing surgical management of incisional hernia are primary versus mesh repair and open versus laparoscopic repair [5]. The aim of this study was to determine the rate of development of incisional hernia 6 months and 1 year after the surgery and to evaluate different surgical techniques and suture materials for abdominal closure after emergency midline laparotomy, and, also, to evaluate the prevalence of postoperative complications among the studied groups.


  Patients and methods Top


This prospective study was conducted on patients (of any age and sex) with abdominal emergency who had underwent surgical treatment at the Emergency Department of Aswan University Hospital, Egypt, during a period from 1 June 2014 to 30 January 2015. In total, 160 patients underwent urgent exploratory laparotomy, and an analysis of their records was carried out. Data were collected by the authors and our residents in the emergency departments of Aswan University Hospital. The consent was obtained from the patients or their guardians and relatives. The patients were divided into two groups (A and B). Group A (80 patients) comprised patients suffering from peritonitis due to, for example, perforated peptic ulcer, perforated appendix, etc., and thus were considered as potentially septic wounds. Furthermore, group A was divided into two subgroups (A1 and A2). Subgroup A1 included 40 patients for whom the midline laparotomy incision was closed by using the continuous suture technique plus some interrupted sutures in between using Vicryl (polyglactin; ETHICON company, USA) suture material (multifilamentous − slowly absorbable material). Subgroup A2 included 40 patients for whom the midline laparotomy incision was closed by using the continuous suture technique with no interrupted sutures in between using Prolene (polypropylene) suture material (monofilamentous − nonabsorbable material). Group B (80 patients) comprised patients suffering from intraperitoneal hemorrhage (IPHge) due to, for example, splenic tear, liver tear, etc., and thus they were considered as septic wounds. In addition, group B was divided into two subgroups (B1 and B2). Subgroup B1 included 40 patients for whom the midline laparotomy incision was closed by using the continuous suture technique plus some interrupted sutures in between using Vicryl suture material. Subgroup B2 included 40 patients for whom the midline laparotomy incision was closed by using the continuous suture technique with no interrupted sutures in between using Prolene suture material. The collected data included the following: (a) sociodemographic and clinical data for each patient [age, sex, marital status, children, occupation or job, special habits, residence, country (rural or urban), date of admission, date of discharge, and length of hospital stay]; (b) pre-existing risk factors (obesity-BMI, DM, malignancy, immunosuppressive agents, corticosteroids, smoking, chronic chest diseases, liver cirrhosis, chronic renal failure, radiotherapy, and previous laparotomy); (c) findings on investigations (laboratory and radiological) into the diagnosis of each patient and then their treatment by urgent exploratory laparotomy; (d) postoperative complications (wound hematoma, wound infection, wound dehiscence, abdominal distension, chest infection, vomiting, and re-exploration); and (e) follow-ups of each patient on the development of incisional hernia at 6 months and 1 year diagnosed both clinically and by using ultrasound.

Statistical analysis

Data were analyzed using the STATA intercooled (version 9.2) (STATA Statistical Software, USA). Quantitative data were analyzed using the Student t-test to compare the means of the two groups. When the data were not normally distributed, the Mann–Whitney test was used. Qualitative data were compared using either the c2-test or Fisher’s exact test. P-value was considered significant if it was less than 0.05.


  Results Top


This study represents 1 year follow-up of two prospective groups of patients. Group A (potentially septic wounds − peritonitis) included 80 patients − 64 (80%) males and 16 (20%) females. Group B (aseptic wounds − IPHge) included 80 patients − 60 (75%) males and 20 (25%) females. All patients (160) of groups A and B underwent urgent midline laparotomy. Sociodemographic data of the patients are shown in [Table 1]. There was an insignificant difference between the two studied groups regarding sex, residence, and country. Both studied cohorts included more men than women. The mean age of group A was 39.14 years (15–77 years) compared with 29.83 years (15–75 years) in group B (P≤0.0001). A total of 54 (67.5) patients were married in group A and 28 (35%) in group B (P≤0.0001). The number of children was significantly increased in group A than in group B (P=0.002 and 0.04 as regards boys and girls, respectively). Manual workers were more common in group A: 48 (60%) patients compared with 28 (35%) patients in group B (P≤0.0001) ([Figure 1] and [Figure 2]).
Table 1: Comparison between the two groups as regards sociodemographic factors

Click here to view
Figure 1: Comparison between the two groups as regards age.

Click here to view
Figure 2: Comparison between the two groups as regards sex.

Click here to view


Hospital stay in group A ranged from 4 to 15 days (mean=7.45) compared with 1–9 days in group B (mean=5.18; P≤0.0001), as shown in [Table 2].
Table 2: Comparison between the two groups as regards length of stay

Click here to view


As regards pre-existing risk factors in both groups, there was significant increase in BMI and smoking in group A in comparison with group B (P=0.002 and 0.01, respectively); in addition, there was highly significant increase in serum albumin and hemoglobin in group A in comparison with group B (P≤0.0001 in both). But there was insignificant difference between the two studied groups regarding DM, liver cirrhosis, and chronic chest diseases, as shown in [Table 3] ([Figure 3] and [Figure 4]).
Table 3: Comparison between the two groups as regards pre-existing risk factors

Click here to view
Figure 3: Comparison between the two groups as regards BMI.

Click here to view
Figure 4: Comparison between the two groups as regards smoking.

Click here to view


Regarding the diagnosis in group A, perforated duodenal ulcer was the commonest cause of peritonitis [46 (57.5%) patients], followed by perforated appendix [16 (20%) patients], perforated sigmoid [eight (10%) patients], perforated cecum [two (2.5%) patients], pyogenic liver abscess [two (2.5%) patients], mesenteric vascular occlusion [two (2.5%) patients], acute pancreatitis [two (2.5%) patients], and pelvic abscess [two (2.5%) patients], as shown in [Figure 5].
Figure 5: Diagnosis in group A. DU, duodenal ulcer; MVO, mesenteric vascular occlusion.

Click here to view


Splenic tear was the commonest cause of IPHge in group B [42 (52.5%) patients], followed by liver tear [14 (17.5%) patients], mesentric tear [eight (10%) patients], omental tear [six (7.5%) patients], stomach tear [two (2.5%) patients], diaphragmatic tear [two (2.5%) patients], splenic and liver tears [two (2.5%) patients], and, lastly, retroperitoneal hematoma [four (5%) patients], as shown in [Figure 6].
Figure 6: Diagnosis in group B. IPHge, intraperitoneal hemorrhage.

Click here to view


As regards postoperative complications, there was a significant increase in wound infection, chest infection, and vomiting in group A in comparison with group B (P=0.002, 0.01, and 0.02, respectively). But there was insignificant difference between the two groups regarding wound hematoma (P=0.06), wound dehiscence (P=0.28), abdominal distension (P=0.11), and re-exploration (P=0.68), as shown in [Table 4] and [Figure 7].
Table 4: Comparison between the two groups as regards postoperative complications

Click here to view
Figure 7: Comparison between the two groups as regards postoperative complications.

Click here to view


At the 6 months postoperative follow-up, regarding the development of incisional hernia, there was a significant increase in the incidence of incisional hernia in group A [10 (12.5%) patients] in comparison with group B [two (2.5%) patients; P=0.02], diagnosed both clinically and by using ultrasound.

At the 1 year postoperative follow-up, there was a significant increase in the incidence of incisional hernia in group A [20 (25%) patients] compared with group B [eight (10%) patients; P=0.01], diagnosed both clinically and by using ultrasound. Moreover, there was a significant increase in the incidence of incisional hernia at 12 months compared with 6 months of follow-up in group A (P=0.04) and also in group B (P=0.05), as shown in [Table 5].
Table 5: Comparisons between the two groups as regards follow-up for the development of incisional hernia

Click here to view


At 6 and 12 months postoperative follow-up, there was an insignificant difference between subgroups A1 and A2 regarding the development of incisional hernia (P=0.50 at 6 months and 0.30 at 12 months). Moreover, there was an insignificant difference between subgroups B1 and B2 (P=0.49 at 6 months and P=1.00 at 12 months) regarding the development of incisional hernia, as shown in [Table 6] and [Table 7].
Table 6: Incidence of incisional hernia at 6 months

Click here to view
Table 7: Incidence of incisional hernia at 12 months

Click here to view


Of all the studied patients (groups A and B), 12 (7.5%) patients were suffering from incisional hernia at 6 months, whereas 28 (17.5%) patients were suffering from incisional hernia at 12 months after urgent midline laparotomy incision. Thus, the rate of incisional hernia increased significantly from 7.5% at 6 months to 17.5% at 1 year (P=0.007) ([Figure 8]).
Figure 8: Incidence of incisional hernia at 6 months and 1 year.

Click here to view



  Discussion Top


Age above 45 years emerged as a significant risk factor for incisional hernia [6]. This can be attributed to delayed wound healing in older individuals, with changes in fibroblast migration [7]. In the present study, the mean age of group A was 39.14 years compared with 29.83 years in group B, and thus there was a highly significant increase in age in group A compared with group B (P≤0.0001). Many studies suggest that men are at greater risk than women for developing incisional hernia [8]. Other studies have not found significant effect of sex [9]. In this study, there was insignificant difference between studied groups regarding sex (P=0.45). Many studies identify adiposity as a risk factor for incisional hernia development [10]. This concurs with our results, according to which there was significant increase in BMI in group A compared with group B (P=0.002). Anemia, DM, and underling malignant disorder were all identified as independent risk factors by using single factor analysis [6],[11],[12]. In our study, there was highly significant increase in hemoglobin and serum albumin in group A in comparison with group B (P≤0.0001 in both), whereas there was insignificant difference regarding DM and underlying malignant disorder between the two groups (P=0.62 and 1.0, respectively). It is well-established that smoking promotes both hernia recurrence and hernia formation. In addition, smokers have been shown to have not only a significant increased rate of relapse after inguinal hernia repair but also a four-fold risk for developing incisional hernia [13]. In the present study, there was significant increase in smoking in group A compared with group B (P=0.01). Wound infection is probably an important risk factor for the development of incisional hernia and wound dehiscence [14]. This concurs with our results, according to which there was significant increase in the incidence of wound infection in group A compared with group B (P=0.002). None of the nine randomized trials was able to show significant difference in wound dehiscence rate after different types of abdominal incisions [15]. But other investigators reported a 1.7% wound dehiscence rate after midline laparotomy [16]. In the present study, we found insignificant difference in the incidence of wound dehiscence rate in group A compared with group B (7.50 vs. 2.5%; P=0.28). But there was significant increase in the incidence of postoperative vomiting and chest infection in group A compared with group B (P=0.02 and 0.01, respectively). Incisional hernia remains the most frequent long-term complication in visceral surgery after midline laparotomy; the rate 1 year after laparotomy was within the range of 9–20% [2]. The rate of incisional hernia increased significantly from 12.6% at 1 year to 22.4% at 3 years after midline laparotomy [3]. Harlaar et al. [17] reported that, the incisional hernia remains the most common complication after median laparotomy, with reported incidence varying between 2 and 20% within 1 year of follow-up. Other investigators found that, 31.5% of all incisional hernias developed in the first 6 months after surgery, 54.5% by 12 months, 74.8% by 2 years, and 88.9% by 5 years [6]. In the present study, the percentage of development of incisional hernia in all studied patients was 7.5% at 6 months and 17.5% at 1 year after urgent midline laparotomy, and thus there was significant increase in the incidence of incisional hernia at 1 year compared with 6 months after the surgery (P=0.007). There was a high incidence of incisional hernia following operations for peritonitis because, as a rule, the wound becomes infected [4]. Wound infection is probably an important predisposing factor for the development of incisional hernia [18]. This concurs with our results, according to which there was a significant increase in the incidence of development of incisional hernia in group A (potentially septic wounds − peritonitis) compared with group B (aseptic wounds − IPHge) at 6 months and 1 year after the surgery (P=0.02 and 0.01, respectively). Running sutures and short-stitch technique using slowly absorbable suture materials seem to be the best available options; however, strong clinical data are not yet available to support any technique as the method of choice [19]. Regarding the type of suture material, several meta-analyses report the lowest incidence of incisional hernia for monofilaments, nonresorbable, or long-term resorbable suture material [20]. The theoretical advantage of nonresorbable suture material in hernia prevention must, however, be balanced against a significant higher incidence of fistula formation and higher rates of postoperative wound pain, due to permanent mechanical tissue irritation [21]. In the present study, there was an insignificant difference in the incidence of development of incisional hernia at 6 months and 1 year postoperative follow-up regarding the technique of closure of urgent midline laparotomy and the used suture materials [continuous suture plus some interrupted sutures in between using multifilamentous slowly absorbable suture material (Vicryl) compared with continuous suture only using monofilamentous nonabsorbable suture material (Prolene)]; P value was 0.50 (comparing subgroups A1 with A2) and 0.49 (comparing subgroups B1 with B2) at 6 months, whereas it was 0.30 (comparing subgroups A1 with A2) and 1.00 (comparing subgroups B1 with B2) at 1 year.


  Conclusion Top


The incisional hernia remains the most common complication after midline laparotomy representing 7.5% at 6 months and 17.5% at 1 year follow-up for all the studied patients in our study. Incisional hernia was significantly increased in patients suffering from peritonitis (group A) than in those patients suffering from IPHge (group B) at 6 months (12.5 vs. 2.5%; P=0.02) and at 1 year (25 vs. 10%; P=0.01) follow-up after urgent midline laparotomy. There were a number of preoperative risk factors in our studied groups; these include obesity (BMI), smoking, and age, which were significantly increased in group A than in group B (P=0.02, 0.01, and <0.0001, respectively). In addition, there were a number of postoperative complications; these include wound infection, chest infection, and vomiting, which were significantly increased in group A than in group B (P=0.002, 0.01, and 0.02, respectively). Regarding the surgical techniques and suture materials used for closure of urgent midline laparotomy, there was insignificant difference between closure of urgent midline incision by continuous suture plus some interrupted sutures in between using slowly absorbable multifilamentous suture material [Vicryl (polyglactin)] and continuous suture only using nonabsorbable monofilamentous suture material [Prolene (polypropylene)] at 6 months and 1 year follow-up in subgroups A1 and A2 (P=0.50 and 0.30, respectively) and B1 and B2 (P=0.49 and 1.00, respectively).

Recommendations

The findings of this study calls for recommending that, although the midline incision is easy and fast, there should be caution with its use because of the high incidence of incisional hernia. The use of midline incision should be limited to emergency surgery and exploratory surgery in unlimited access to the entire abdominal cavity is necessary or useful. Pre-existing risk factors should be carefully managed before surgery − for example, controlling DM, stopping smoking, reduction of weight in obese patients, correction of anemia and hypoproteinemia, and treatment of chest infection specially in elective midline laparotomy. Any effort should be made to guard against occurrences of postoperative complications such as wound hematoma, wound infection, wound dehiscence, abdominal distension, vomiting, and chest infection. Running sutures and short-stitch technique with some interrupted sutures in between using either slowly absorbable or nonabsorbable suture materials may be considered to decrease the rate of development of incisional hernia after midline laparotomy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Schumpelick V, Junge K, Klinge U, Conze J. Incisional hernia: pathogenesis, presentation and treatment. Dtsch Arztebl 2006; 103:A2553–A2558.  Back to cited text no. 1
    
2.
Diener MK, Voss S, Jensen K, Buchler MW, Seiler CM. Elective midline laparotomy closure: the INLINE. Systemic review and meta-analysis. Ann Surg 2010; 251:843–856.  Back to cited text no. 2
    
3.
Fink C, Baumann P, Wente MN, Knebel P, Bruckner T, Ulrich A et al. Incisional hernia rate 3 years after midline laparotomy. Br J Surg 2014; 101:51–54.  Back to cited text no. 3
    
4.
Williams NS, Bulstrode CJK, O’Connell PR. Hernias, umbilicus and abdominal wall. In: Edward Arnold (editor). Baily & love’s short practice of surgery. 25th ed. London: Edward Arnold; 2008. 965–990.  Back to cited text no. 4
    
5.
Brunicardi FC, Anderson DK, Bellair TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. Abdominal wall, omentum, mesentery and retroperitoneum. In: Editor in-Chief; F. Charlies Brunicardi, Associated Editors, Dana K. Anderson, et al. Schwortz’s principles of surgery. 9th ed. New York, NY: Edward Arnold; 2009. 1267–1282.  Back to cited text no. 5
    
6.
Höer J, Lawong G, Klinge U, Schumpelick V. Factors influencing the development of incisional hernia. A retrospective study of 2,983 laparotomy patients over a period of 10 years. Chirurg 2002; 73:474–480.  Back to cited text no. 6
    
7.
Reed MJ, Ferara NS, Vernon RB. Impaired migration, integrin function, and actin cytoskeletal organization in dermal fibroblasts from a subset of aged human donors. Mech Ageing Dev 2001; 122:1203–1220.  Back to cited text no. 7
    
8.
Sørensen LT, Hemmingsen UB, Kirkeby LT, Kallehave F, Jørgensen LN. Smoking is a risk factor for incisional hernia. Arch Surg 2005; 140:119–123.  Back to cited text no. 8
    
9.
Regnard JF, Hay JM, Rea S, Fingerhut A, Flamant Y, Maillard JN. Ventral incisional hernias: incidence, date of recurrence, localization and risk factors. Ital J Surg Sci 1988; 18:259–265.  Back to cited text no. 9
    
10.
Derzie AJ, Silvestri F, Liriano E, Benotti P. Wound closure technique and acute wound complications in gastric surgery for morbid obesity: a prospective randomized trial. J Am Coll Surg 2000; 191:238–243.  Back to cited text no. 10
    
11.
Mäkelä JT, Kiviniemi H, Juvonen T, Laitinen S. Factors influencing wound dehiscence after midline laparotomy. Am J Surg 1995; 170:387–390.  Back to cited text no. 11
    
12.
Franchi M, Ghezzi F, Buttarelli M, Tateo S, Balestreri D, Bolis P. Incisional hernia in gynecologic oncology patients: a 10-year study. Obstet Gynecol 2001; 97(Pt 1):696–700.  Back to cited text no. 12
    
13.
Sorensen LT, Friis E, Jorgensen T, Vennits B, Andersen BR, Rasmussen GI, Kjaergaard J. Smoking is a risk factor for recurrence of groin hernia. World J Surg 2002; 26:397–400.  Back to cited text no. 13
    
14.
Israelsson LA, Jonsson T. Incisional hernia after midline laparotomy: a prospective study. Eur J Surg 1996; 162:125–129.  Back to cited text no. 14
    
15.
Burger JW, van’t Riet M, Jeekel J. Abdominal incisions: techniques and postoperative complications. Scand J Surg 2002; 91:315–321.  Back to cited text no. 15
    
16.
Waldhausen JH, Davies L. Pediatric postoperative abdominal wound dehiscence: transverse versus vertical incisions. J Am Coll Surg 2000; 190:688–691.  Back to cited text no. 16
    
17.
Harlaar JJ, Deerenberg EB, van Ramshorst GH, Lont HE, van der Borst HE, Schouten WR et al. A multicentric randomized control trial evaluating the effect of small stitches on the incidence of incisions hernia in midline incisions. BMC Surg 2011; 11:20.  Back to cited text no. 17
    
18.
Eisner L, Harder F. Incisional hernias. Chirurg 1997; 68:304–309.  Back to cited text no. 18
    
19.
Seiler CM, Bruckner T, Diener MK, Papyan A, Golcher H, Seidlmayer C et al. Interrupted or continuous slowly absorbable sutures for closure of primary elective midline abdominal incisions: a multicenter randomized trial (INSECT: ISRCTN24023541). Ann Surg 2009; 249:576–582.  Back to cited text no. 19
    
20.
Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal facial closure; a meta-analysis. Ann Surg 2000; 231:436–442.  Back to cited text no. 20
    
21.
Rucinski J, Margolis M, Panagopoulos G, Wise L. Closure of the abdominal midline fascia: meta-analysis delineates the optimal technique. Am Surg 2001; 67:421–426.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Patients and methods
  Results
  Discussion
  Conclusion
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed210    
    Printed0    
    Emailed0    
    PDF Downloaded37    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]