Closing the abdominal wall in high-risk abdominal surgery

Background: Incisional hernia and Wound dehiscence are potentially serious complications to midline incisions. Recent studies have shown that a meticulous suturing technique can reduce the rate of these complications significantly, but even with optimal technique there is 5-15% risk of abdominal wall complications. At Capio S:t Görans hospital the new abdominal wall closure technique 2012 was implemented in a standardised quality improvement project. The aim of these studies was to investigate the effect of a structured implementation of the new surgical technique, to study which risk factors for incisional hernia and wound dehiscence are relevant in a Swedish population and to test new techniques to reinforce the abdominal wall after open abdominal surgery.

Methods: Study 1. All procedures performed via a midline incision 2010-2011 before, and 2016-2017 after the new protocol was introduced at Capio S:t Görans Hospital were identified and assessed for complications and risk factors for wound dehiscence and incisional hernias. Study 2. All procedures registered in the Swedish Colorectal Cancer Register (SCRCR) 2007–2013 were identified. Patients with comorbid disease diagnoses, registered at admissions and visits prior to the procedure and relevant to this study, were obtained from the National Patient Register (NPR). Data on occurrence of incisional hernias were obtained by combining data from the SCRCR and the NPR). Study 3. Like study 2 all open abdominal procedures for colorectal cancer registered in the SCRCR 2007–2013 were identified. Potential risk factors for wound dehiscence were identified by cross-matching between the SCRCR and the NPR. The endpoint in this study was reoperation for wound dehiscence registered in either the SCRCR or NPR. Study 4. Sixteen patients with three or more risk factors for wound dehiscence or incisional hernia were included. A TIGR® Matrix mesh was placed on the aponeurosis with an overlap of five cm on either side and fixated with continuous monofilament polydioxanone suture. All postoperative complications were registered at clinical follow-up.

Results: Study 1. After the implementation of new guidelines, 93% of procedures were performed using the standardised technique for abdominal wall closure. There was no significant difference in incidence of incisional hernia or wound dehiscence between the two periods. BMI>25 and postoperative wound infection were found to be independent risk factors for incisional hernia. Male sex, high age, chronic obstructive pulmonary disease, and postoperative wound infection were risk factors for wound dehiscence. Study 2. The cumulative incidence of incisional hernia in the population was 5.3%. In multivariate analysis male gender, operation time exceeding 180 min, body mass index (BMI) > 30, age < 70 years and postoperative wound complication were significant risk factors for incisional hernia. Study 3. In multivariable analysis, age > 70 years, male gender, BMI > 30, chronic obstructive pulmonary disease, generalised inflammatory disease, and duration of surgery less than 180 min were significant risk factors for wound dehiscence. The hazard ratio for postoperative death was 1.24 for patients who underwent reoperation for wound dehiscence compared with that for controls. Study 4. One patient developed a seroma that needed drainage and antibiotic treatment. One patient had a wound infection that needed antibiotic treatment. There was no complication requiring a reoperation. No wound dehiscence or incisional hernia was seen.

Conclusions: High age, high BMI, long operation time, chronic obstructive pulmonary disease, systemic inflammatory disease, and male gender should be considered risk factors for postoperative adverse events after a midline incision. Postoperative wound infection is a strong predictor of incisional hernia and wound dehiscence and all measures possible should be taken to avoid wound infection. Structured implementation of a standardised surgical technique is possible and has a long-lasting effect. Implantation of TIGR® Matrix mesh is a feasible way to reinforce the abdominal wall after high-risk surgery.

List of scientific papers

I. Small Stitch Small Bites technique: a long-term follow-up. [Submitted]

II. Incisional hernia after surgery for colorectal cancer: a population-based register study. Int J Colorectal Dis. 2019 Oct;34(10):1757-1762.
https://doi.org/10.1007/s00384-018-3124-5

III. Incidence of wound dehiscence after colorectal cancer surgery: results from a national population-based register for colorectal cancer. Int J Colorectal Dis. 2018 Oct;33(10):1411-1417.
https://doi.org/10.1007/s00384-019-03390-3

IV. Prophylactic Resorbable Synthetic Mesh to Prevent Wound Dehiscence and Incisional Hernia in High High-risk Laparotomy: A Pilot Study of Using TIGR Matrix Mesh. Front Surg. 2016 May 18;3:28.
https://doi.org/10.3389/fsurg.2016.00028