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Purpose The small bites (SB) technique for closure of elective midline laparotomies (EMLs) and a prophylactic mesh (PM) in high-risk patients are suggested by the guidelines to prevent incisional hernias (IHs) and fascial dehiscence (FD). Our aim was to implement a protocol combining both the techniques and to analyze its outcomes. Methods Prospective data of all EMLs were collected for 2 years. Results were analyzed at 1 month and during follow-up. The incidence of HI and FD was compared by groups (M = Mesh vs. S = suture) and by subgroups depending on using SB. Results A lower number of FD appeared in the M group (OR 0.0692; 95% CI 0.008–0.56; P = 0.01) in 197 operations. After a mean follow-up of 29.23 months (N = 163; min. 6 months), with a lower frequency of IH in M group (OR 0.769; 95% CI 0.65–0.91; P P P P Conclusion Following the protocol using PM and SB showed a lower rate of FD and HI. A PM is safe and effective for the prevention of both HI and FD after MLE, regardless of the closure technique used.

This article reviews evidence-based techniques for abdominal closure and management strategies when abdominal wall closures fail. In particular, optimal primary fascial closure techniques, the role of prophylactic mesh, considerations for combined hernia repair, closure techniques when the fascia cannot be closed primarily, and management approaches for fascial dehiscence are reviewed.

espanolIntroduccion: El onfalocele gigante se define por defecto de pared abdominal de 5 cm de diametro a mas o presencia de herniacion hepatica. Se ha descrito el uso de toxina botulinica como coadyuvante en la reconstruccion de la pared abdominal en adultos, su utilidad en pediatria aun es poco descrito, pero si muestra seguridad y eficacia. Reporte de Caso: Paciente femenino de 40 semanas de edad gestacional con onfalocele gigante con defecto amplio de aproximadamente 9 centimetros, en quien a los 75 dias de vida se le aplica inyecciones de toxina botulinica alrededor del defecto y es intervenida a la semana para al cierre definitivo de pared abdominal, la cual se logra sin tension ni intercurrencias post operatorias. Conclusion: El uso de toxina botulinica muestra tener alta efectividad para lograr un cierre de pared abdominal en pacientes con onfalocele gigante. EnglishIntroduction: Giant omphalocele is an abdominal wall defect of 5cm in diameter or more or presence of liver herniation. The use of botulinum toxin has been described as an adjunct therapy in the reconstruction of the abdominal wall in adults. Its use in pediatric patients is still little described but it does show safety and efficacy. Case Report: 40-week gestational-age female patient with a giant omphalocele with a wide defect measuring approximately 9 centimeters, in whom at 75 days of life botulinum toxin injections were applied around the defect and operated a week after for definitive abdominal wall closure which was achieved without tension or post-operative intercurrences. Conclusion: The use of botulinum toxin is shown to be highly effective in achieving abdominal wall closure in infant patients with giant omphalocele.

The first edition of the World Society of Emergency Surgeons (WSES) guidelines on the indications and treatment of open abdomen in trauma as well as in non-trauma patients was published at the end of 2018. Publications from 1980 to 2017 were included in the evaluation. Based on the GRADE system each publication was checked for its evidence and evaluated in a Delphi process. In this article the aspects of the guidelines are presented and commented on.

Background Conventional mass closure uses suture-to-wound length ratio of 4:1 ('long stitch', LS). 'Short stitch' (SS) has a suture-to-wound length ratio of more than 4 and incorporates only the linea alba, which may reduce tension and pain. We compared the post-operative pain after laparotomy closure using LS and SS. Methods Patients undergoing elective midline laparotomy through standardized incisions in two tertiary hospitals from February 2017 to September 2018 were randomized to either LS or SS. The primary outcome was post-operative patient-controlled analgesia morphine usage at 24 h. Secondary outcomes were presence of surgical site infection and length of hospital stay (LOHS). Categorical variables were analysed using chi-squared analysis. Outcomes of study were tested for normal distribution. Skewed data were analysed using Mann-Whitney U-test. Results Eighty-six patients were recruited (42 SS and 44 LS). The median age was 66 (interquartile range (IQR) 15). Majority were males (62.8%) and Chinese (50%). The median incision length was 17 cm in both groups. The median patient-controlled analgesia morphine usage 24 h post-operatively did not differ significantly (SS 21 mg, IQR 28.3; LS 18.5 mg, IQR 33.8, P = 0.829). The median pain score at rest (SS 1, IQR 1; LS 1, IQR 2, P = 0.426) and movement (SS 3, IQR 1; LS 3, IQR 2, P = 0.307) did not differ significantly. LOHS was shorter in the SS group (SS 6, IQR 4; LS 8, IQR 5, P = 0.034). The rate of surgical site infection trended lower in the SS group with no statistical difference. Conclusion There were no differences in post-operative pain between SS and LS but we found that there were shorter LOHS in SS arm as secondary outcome.

An incisional hernia is being a universal problem and topic of discussion worldwide. There is no clear-cut guideline of abdominal wall closure after major abdominal surgeries that can effectively prevent the occurrence of incisional hernia. We found out that most of the patients presented with pain over previous surgery scar with swelling. The defect was usually larger than 2 cm. Most postoperative patients complaint of pain, seroma, and hematoma formation. There was a minimal recurrence rate after onlay mesh repair in our setup.

Purpose To report outcomes of sutured and sutureless closure for gastroschisis across a large multi-institutional cohort. Methods A retrospective study of infants with uncomplicated gastroschisis at 11 children's from 2014 to 2016 was performed. Outcomes of sutured and sutureless abdominal wall closure were compared. Results Among 315 neonates with uncomplicated gastroschisis, sutured closure was performed in 248 (79%); 212 undergoing sutured closure after silo and 36 undergoing primary sutured closure. Sutureless closure was performed in 67 (21%); 37 primary sutureless closure, 30 sutureless closure after silo placement. There was no significant difference in gestational age, gender, birth weight, total days on TPN, and time from closure to initial oral intake or goal feeds. Sutureless closure patients had less general anesthetics, ventilator use/time, time from birth to final closure, antibiotic use after closure, and surgical site/deep space infections. Subgroup analysis demonstrated primary sutureless closure had less ventilator use and anesthetics than primary sutured closure. Sutureless closure after silo led to less ventilator use/time, anesthetics, and antibiotics compared to those with sutured closure after silo. Conclusion Sutureless abdominal wall closure of neonates with gastroschisis was associated with less general anesthetics, antibiotic use, surgical site/deep space infections, and decreased ventilator time. These findings support further prospective study by our group. Level of Evidence Level III.

Introduction We report the case of a successful management with combined aggressive surgery and negative pressure therapy, to treat a severely ill-septic patient, affected by multiple chronic enterocutaneous fistulas. Presentation of case A 26-year-old female patient presented with multiple pelvic and intra-abdominal abscesses, enterocutaneous fistulas and central venous catheter-related bacteraemia in extremely poor general conditions. The patient underwent both an abdominal CT which showed multiple digestive loops stuck and apparently fistulised and an abdominal-pelvic MRI, confirming the CT findings, and demonstrating a third fistula involving the Pouch and responsible for a pelvic and retroperitoneal chronic abscess. Given the patient's septic condition, despite several attempts of conservative therapies, an aggressive surgical approach was adopted. After temporary abdominal wall closure, the patient underwent Vacuum Assisted Closure therapy in order to close the abdominal wall and drain the residual abscess. The patient was discharged at the 35th post-operative day in good general conditions. Discussion This case is about a complex, long-lasting clinical scenario, progressively leading a young woman to death despite several attempts of conservative therapy, sometimes allowed to treat enterocutaneous fistulas. The use of negative pressure therapy to manage open abdomen is still controversial. Patients affected by enterocutaneous fistulas are in need of adequate nutritional support due to their hypercatabolic state, secondary both to the fluid loss and the concomitant inflammatory status. Conclusion When conservative management fails and the patient shows septic complications, a multidisciplinary aggressive approach, including surgery, negative-pressure therapy and hyperbaric oxygen therapy is required to treat this life-threatening condition., Highlights • Using negative pressure therapy to deal with difficult abdominal wall closure. • Multidisciplinary team work is essential to optimize patients' surgical outcomes. • Highly-demolitive surgery can benefit from the use of negative pressure therapy.

Background: Technique of anterior abdominal wall closure (AAWC) determines wound-related surgical complications. Residents in obstetrics and gynecology and surgery departments perform most midline abdominal wall closure; data is lacking on how it is being done. This study identifies abdominal wall closure techniques used. Methods: A descriptive study was carried out from October 2015 to May 2016. Results: 71 (35 surgical, 36 ObGyn) residents completed a self-administered questionnaire. Knowledge of midline abdominal closure was acquired from medical officers (58.6%) or consultants before residency (28.6%). Absorbable suture was preferred for clean wounds by 75% of residents; 70% used size 1 suture for fascial closure. Most residents (95.7%) closed fascia in clean wound by continuous suturing. Interrupted suturing was preferred in contaminated and dirty wounds. Half of the residents in both groups would close skin in contaminated wounds, while 16% of surgery and 9.4% ObGyn will close skin in dirty wounds. Conclusion: Inconsistencies exist in anterior abdominal wall closure between groups of residents despite presence of clear guidelines. It is important to harmonize training on AAWC at the tertiary hospital. Keywords: Abdominal closure, Midline incision, Wound complications

Background: Incisional hernia (IH) is the main complication after laparotomy. The objective of this meta-analysis was to evaluate the effectiveness of closure technique modification (CTM) for reducing the incidence of IH to provide objective support for its recommendation.Methods: A meta-analysis was performed according to the PRISMA guidelines. The primary objective was to determine the incidence of IH, and the secondary objective was to determine the incidence of acute evisceration and postoperative complications. Only published clinical trials were included. The risk of bias was analyzed, and the random effects model was used to determine statistical significance.Results: Nine studies comparing 2,612 patients were inclued. The incidence of IH was significantly lower in the CTM group than in the control group, with an OR of 0.39 (95% CI 0.26-0.57). The incidence of acute postoperative evisceration was also reduced, with an OR of 0.46 (95% CI 0.23-0.92). Associated complications, including hematoma, seroma, and postoperative pain, could not be analyzed; however, CTM did not increase the risk of surgical site infection.Conclusion: CTM for midline laparotomy significantly reduces the incidence of IH compared to conventional closure. Limitations of the analysis included differences in follow-up, patient selection, diagnostic methods, and the reporting of postoperative complications among the studies.Funding Information: No funding was received.Registration: This study was prospectively registered in the PROSPERO database under registration number CRD42021231107.

Background:. Laparotomy closures fail due to suture pull-through. I hypothesize that a suturable mesh may limit pull-through via mechanisms of force distribution and fibrous encapsulation of the device filaments. Methods:. Fifteen domestic swine 74 kg in size were randomly allocated to three groups for laparotomy closure with either size 0 suturable mesh, number 1 suturable mesh, or number 1 polypropylene. All three devices were placed in running fashion with 1-cm bites and 1-cm travels. Primary endpoints were hernia formation at 13 weeks and a semiquantitative analysis of the histological tissue response. Secondary endpoints included adhesions, surgical site occurrence (SSO), and documentation of “loose sutures.” Results:. There were numerically fewer hernias in the number 1 suturable mesh group. Nine of the 10 suturable mesh devices were well encapsulated within the tissues and could not be pulled away, whereas four of the five polypropylene sutures were loose. Adhesions were least for number 1 suturable mesh. Histologically, the suturable mesh implanted devices showed good fibrovascular ingrowth and were judged to be “nonirritants.” The soft-tissue response was statistically greater (P = 0.006) for the number 1 suturable mesh than for the number 1 polypropylene. Conclusions:. The mechanism by which meshes support closure sites is clearly demonstrated with this model. Suturable mesh has the potential to change surgical algorithms for abdominal wall closure.

BACKGROUND Primary abdominal wall closure after pediatric liver transplantation (PLT) is neither always possible nor advisable, given the graft-recipient size discrepancy and its potential large-for-size scenario. Our objective was to report the experience accumulated with delayed sequential closure (DSC) guided by Doppler ultrasound control. METHODS Retrospective analysis of DSC performed from 2013 to March 2020. RESULTS Twenty-seven DSC (26.5%) were identified out of 102 PLT. Transplant indications and type of grafts were similar among both groups. In patients with DSC, mean weight and GRWR were 9.4 ± 5.5 kg (3.1-26 kg) and 4.7 ± 2.4 (1.9-9.7), significantly lower and higher than the primary closure cohort, respectively. The median time to achieve definitive closure was 6 days (range 3-23 days), and the median number of procedures was 4 (range 2-9). Patients with DSC had longer overall PICU (22.5 ± 16.9 vs. 9.1 ± 9.7 days, p

We describe a novel 'pubic osteotomy minimal' (POM) done on body of pubis just lateral to the insertions of rectus abdominis and adductor longus muscles to bring rectus abdominis in midline without tension for abdominal wall closure without tension. In one patient, during pubic ramotomy, we missed middle of ramus and did osteotomy on the body on pubis found afterwards. Following good outcome, we did POM in another 17 patients. Abdominal wall closure was possible without tension and found satisfactory in all 18 patients in follow up. None had bladder wall dehiscence.

Background Mesh suture used in high-tension wound closures produces large knots susceptible to increased palpability, infection, and foreign body response; yet has superior tensile strength and increased resistance to cutting through tissue compared to standard suture. This study investigates mesh suture fixation in abdominal tissue with a knotless novel, low-profile anchor-clip. Methods Single and double end fixation of mesh suture in swine rectus abdominus fascia with an anchor-clip, a knot, and predicate device fixation underwent cyclic testing followed by pull-to-failure testing. Results Failure load of standard knot, single corkscrew and double anchor-clip were not statistically different, but were significantly greater than single anchor-clip and double corkscrew fixation (p > 0.05). Conclusions The anchor-clip is ∼60% smaller than a standard knot while maintaining fixation strength when exposed to physiologic forces using double anchor-clip fixation in abdominal wall closure.

Abdominal wall transplantation has been consolidated as an alternative to primary abdominal wall closure in intestinal and multiple organ transplant recipients. Given that it is feasible to obtain the visceral graft and the abdominal wall graft from the same donor, abdominal wall transplantation could offer satisfactory outcomes and be easily coordinated. Non-vascularized fascia is one of the alternatives for abdominal wall closure in transplantation. We report two cases of non-vascularized fascia transplantation in intestinal and multivisceral transplants, respectively. Both donors were young (23 and 18 years old). Both recipients had endured multiple previous surgeries, and no surgical alternatives for primary wall repair could be offered. In both cases, a complete abdominal wall flap was retrieved from the donor, however, due to the characteristics of the recipient's abdominal wall defect, only non-vascularized fascia was used after removing skin and subcutaneous cellular tissue from the graft. Abdominal wall transplantation is an option to consider for abdominal wall closure in patients with multiple previous surgeries and no alternatives for primary wall repair.

BACKGROUND: Abdominal wall closure after intestinal, multivisceral or liver transplantation can be a major challenge. Different surgical techniques have been described to close complex abdominal wall defects, but results remain variable. Two promising transplant techniques have been developed using either non-vascularized or vascularized donor rectus fascia. This systematic review aimed to evaluate the feasibility, safety, and effectiveness of the two techniques. METHODS: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Human studies published between January 2000 and April 2020 were included. Methodological quality appraisal was done using an adapted 10-item standardized checklist. RESULTS: The search resulted in 9 articles including 74 patients. Both techniques proved to be feasible and had similar results. After non-vascularized rectus fascia allotransplantation, there was a slightly higher rate of surgical site infections in the earlier reports. Overall, there were few complications, no fascial graft related rejections or deaths. The included articles scored low on quality appraisal, mostly due to the small number of cases and scarcely reported outcome parameters. CONCLUSIONS: This systematic literature review reports two emerging new techniques for complex abdominal wall closure in transplant patients, with promising results. Standardized data collection in a prospective manner could give us more detailed information about short- and long-term outcomes. Preclinical animal studies are necessary for a thorough investigation of the mechanisms of graft integration, the risk of hernia development and the alloimmune response against the graft. ispartof: TRANSPLANTATION REVIEWS vol:35 issue:4 ispartof: location:United States status: published

Background:TheIncisional hernia is a complication of abdominal surgeries, including laparotomy, and stoma creation. It impairs the patient's quality of life and body image in addition to other complications. Aim of the review:A literature review about the current data for the best, most feasible and most appropriate solutions for abdominal wall repair. Providing a tool for surgeons to choose the best method for repair in a way that prevents incisional hernia development, appropriate for every situation and specific for every patient. Methods:Literature research in American National Center for Biotechnology Information (NCBI), PubMed, Google scholar, Egyptian Knowledge Bank, and science direct. Conclusion:Prevention of incisional hernias could be the key to improving patient outcomes even more after abdominal surgeries. In this overview, currently available methods to decrease the incidence of incisional hernia are discussed. Vast number of these methods has succeeded in giant hernia repair and might succeed in patients with open abdomen as well.

Lower transverse abdominal incisions are typically used by obstetricians/gynecologists and colorectal surgeons. The suture technique and choice of material when closing the abdomen is an essential factor to decrease the risk of incisional hernia. We conducted a nationwide survey among obstetricians/gynecologists and colorectal surgeons investigating the surgical handling of the fascia, rectus muscle, subcutis, peritoneum, and skin, in lower transverse incisions. All departments of obstetrics/gynecology and departments of surgery performing colorectal surgery in Denmark were invited to participate. An online questionnaire was sent to consultant obstetricians/gynecologists and colorectal surgeons. The survey consisted of demographic information together with questions on surgical details. The study was reported according to STROBE guidelines. A total of 252 (64.5%) consultants provided a complete response to the survey. We found that 98.0% of the colorectal surgeons and 65.8% of the obstetricians/gynecologists used monofilament suture when closing the fascia. The majority of the colorectal surgeons used continuous suture and small bites technique. This was only the case for half of the obstetricians/gynecologists. Approximately two thirds of the colorectal surgeons and one third of the OB/GYN used the suture length to wound length ratio > 4:1. Furthermore, we found significant differences between the groups in the handling of subcutis, peritoneum, and skin. We found significant variation in abdominal wall closure techniques in lower transverse incisions. Disagreement between the current guidelines within the specialties together with insufficient evidence on the closure of lower transverse incisions emphasizes the need for education as well as further studies.

Abdominal wall closure after pediatric liver transplantation (pLT) in infants may be hampered by graft-to-recipient size discrepancy. Herein, we describe the use of a porcine dermal collagen acellular graft (PDCG) as a biological mesh (BM) for abdominal wall closure in pLT recipients. Patients

Reconstruction of abdominal wall defects is still a big challenge in surgery, especially where there is insufficient fascia muscular or excessive tension of the defects in emergency and life-threatening scenarios. Indeed, the concept of damage control surgery has been advanced in the management of both traumatic and nontraumatic surgical settings. The strategy requires abridged surgery and quick back to intensive care units (ICU) for aggressive resuscitation. In the damage control laparotomy, patients are left with open abdomen or provisional closure of the abdomen with a planned return to the operating room for definitive surgery. So far, various techniques have been utilized to achieve early temporary abdominal closure, but there is no clear consensus on the ideal method or material for abdominal wall reconstruction. We recently successfully created the selective germline genome-edited pig (SGGEP) and here we aimed to explore the feasibility of in vivo reconstruction of the abdominal wall in a rabbit model with SGGEP meninges grafts (SGGEP-MGs). Our result showed that the SGGEP-MGs could restore the integrity of the defect very well. After 7 weeks of engraftment, there was no sign of herniation observed, the grafts were re-vascularized, and the defects were well repaired. Histologically, the boundary between the graft and the host was very well integrated and there was no strong inflammatory response. Therefore, this kind of closure could help restore the fluid and electrolyte balance and to dampen systemic inflammatory response in damge control surgery while ADM graft failed to establish re-vascularization as the same as the SGGEP-MG. It is concluded that the meninges of SGGEP could serve as a high-quality alternative for restoring the integrity of the abdominal wall, especially for damage control surgery.

Enterocutaneous fistula (ECF) and Enteroatmospheric fistula (EAF) are devastating complications that pose some of the most significant challenges to the general surgeon. Unfortunately, limited reliable evidence exists guiding the care of these complex patients. An experienced multidisciplinary team with adequate resources and special focus on nutritional optimization and complex wound care is essential. Even in the best of circumstances, fistula repair and abdominal wall closure can be daunting. The surgeon must be aware of the causes, contributing factors, preventive measures, and various surgical management and reconstructive strategies in order to achieve optimal outcomes in the care of these complex patients.

Long-term follow-up for pedicled anterolateral thigh (ALT) flap with vastus lateralis and tensor fascia lata for complex abdominal wall reconstruction is rarely reported. This study aimed to evaluate the feasibility of extended pedicled ALT flap. This retrospective review was conducted at a single medical center between 2011 and 2018. A total of 35 patients with complex abdominal wall defects reconstructed with partition (n = 20) or pedicled ALT flap (n = 15) were enrolled. Data on gender, age, fascial defect size, operation time, hospital days, follow-up duration, and complications were obtained. Mann–Whitney test evaluated the differences in continuous data, and Chi-square test analyzed categorical data. The partition technique was associated with 10.15 cm (range 8–14 cm) mean defect size, 146 min average operation time, 13.5 hospital days, and 95.42 months of mean follow-up duration. Short- and long-term complications were observed in seven (35%) and six (30%) cases, respectively. The pedicled ALT flap technique was associated with 13.4 cm (range 10.6–16 cm), 342.86 min average operation time, 22.33 hospital days, and 69.4 months of mean follow-up duration. Short- and long-term complications were observed in six (40%) and five (33%) cases, respectively. Significant differences in defect size, operative time, hospital days, and donor-site skin graft loss (p < 0.05) were observed between the groups. Extended pedicled ALT flap is a reliable option for complex abdominal wall reconstruction. Compared with the partition technique group, the extended pedicled ALT group had closure of larger fascia defects. However, it was associated with a higher risk of donor-site skin graft loss and longer operative time and hospital days.

Research has established that a ≥4:1 suture to wound (S:W) length ratio decreases incisional hernias. We evaluated our ability to obtain a 4:1 S:W length ratio in a surgery residency program. Consecutive abdominal wall closures from 12/1/2013 through 4/9/2015 were reviewed. The length of the incisions and amount of suture used were measured. Patient demographics and operative variables were documented and compared related to inability to obtain a 4:1 ratio. One hundred patients underwent abdominal closure with S:W length measurements. Average wound length was 18.3 cm; average suture length used was 84.5 cm; and average S:W length ratio was 4.6:1. An S:W length ratio of ≥4:1 was achieved in 76% of cases. There was no difference in race, age, gender, BMI, type of procedure, or resident level in obtaining a 4:1 S:W length ratio. There was a significantly higher rate of not achieving a 4:1 ratio when two residents closed. Postoperative infection rate and hernia rate increased when a 4:1 S:W length ratio was not achieved compared with an adequate S:W length ratio. Despite the known importance of achieving a 4:1 S:W length ratio for abdominal closure, it was only achieved in 76% of study patients. Improved education on the importance of fascial closure is needed.

Purpose The aim of this review was to look at relevant data and research on the evolution of ventral hernia repair. Methods Resources including books, research, guidelines, and online articles were reviewed to provide a concise history of and data on the evolution of ventral hernia repair. Results The evolution of ventral hernia repair has a very long history, from the recognition of ventral hernias to its current management, with significant contributions from different authors. Advances in surgery have led to more cases of ventral hernia formation, and this has required the development of new techniques and new materials for ventral hernia management. The biocompatibility of prosthetic materials has been important in mesh development. The functional anatomy and physiology of the abdominal wall has become important in ventral hernia management. New techniques in abdominal wall closure may prevent or reduce the incidence of ventral hernia in the future. Conclusion The management of ventral hernia is continuously evolving as it responds to new demands and new technology in surgery.

Background Intra-abdominal hypertension and abdominal compartment syndrome are significant sources of morbidity and mortality in the post-surgical and trauma patient. Several anatomic variables may contribute to the inability to close the abdomen such as retraction of the abdominal wall and intra-abdominal volume changes. This study seeks to quantify these changes and determined which predominates. Methods Retrospective analysis of computed tomography scans of patients whose abdomens could not be closed secondary to intra-abdominal hypertension. Patients were included who had computed tomography scans available with both an open abdomen and after primary abdominal wall closure. Abdominal wall lengths along with total abdominal, intra-peritoneal, and retroperitoneal cross-sectional areas were measured at two anatomic levels. Results Seven patients’ computed tomography scans were evaluated. The closed abdominal wall lengths averaged 2.3 cm and 2.1 cm longer after closure at each point of measurement (p = 0.002 and p = 0.03). Total abdominal cross-sectional area decreased post-closure by 14% for both measurements (p = 0.009 and p = 0.04). Conclusion Measurable increases in intra-abdominal cross-sectional area and decreases in abdominal wall length both contribute to the inability to safely close the abdomen in patients with intra-abdominal hypertension. These findings support the use of multimodal techniques in the management of the open abdomen.

Background Chemotherapy is associated with postoperative ventral incisional hernia (PVIH) after right hemicolectomy (RHC) for colon cancer, and abdominal wall closure technique may affect PVIH. We sought to identify clinical predictors of PVIH. Methods We retrospectively analyzed patients who underwent RHC for colon cancer from 2008-2018 and later developed PVIH. Time to PVIH was analyzed with Kaplan-Meier analysis, clinical predictors were identified with multivariable Cox proportional hazards modeling, and the probability of PVIH given chemotherapy and the suture technique was estimated with Bayesian analysis. Results We identified 399 patients (209 no adjuvant chemotherapy and 190 adjuvant chemotherapy), with an overall PVIH rate of 38%. The 5-year PVIH rate was 55% for adjuvant chemotherapy, compared with 38% for none (log-rank P < .05). Adjuvant chemotherapy (hazard ratio [HR] 1.65, 95% confidence interval [CI] 1.18-2.31, P < .01), age (HR .99, 95% CI .97-1.00, P < .01), body mass index (HR 1.02, 95% CI 1.00-1.04, P < .01), and neoadjuvant chemotherapy (HR 1.92, 95% CI 1.21-3.00, P < .01) were independently associated with PVIH. Postoperative ventral incisional hernia was more common overall in patients who received adjuvant chemotherapy (46% compared with 30%, P < .01). In patients who received adjuvant chemotherapy, the probability of PVIH for incision closure with #1 running looped polydioxanone was 42%, compared with 59% for incision closure with #0 single interrupted polyglactin 910. Discussion Exposure to chemotherapy increases the probability of PVIH after RHC, and non–short stitch incision closure further increases this probability, more so than age or body mass index. The suture technique deserves further study as a modifiable factor in this high-risk population.

Intra-abdominal hypertension (IAH) leading to abdominal compartment syndrome (ACS) commonly occurs in major burns. To relieve the excess pressure, decompressive laparotomy is done which can lead to an open abdomen. Closure of the abdomen after a decompressive laparotomy is very difficult with bowel oedema. We describe our technique of closing the open abdomen in such situations with a combination of serial abdominal wall closure with a layered mesh and the Rives-Stoppa component separation technique.

Background Prospective studies demonstrate that over one-third of patients undergoing standard suture closure of laparotomy wounds will develop incisional hernias (IHs). Whilst prophylactic mesh has been demonstrated to decrease IH rates in clean laparotomy wounds, mesh has been associated with high rates of seroma formation (>30%), infection (>10%) and pain, discouraging many surgeons from using mesh, especially combined with intestinal surgery. The aim of this study is to review the experience of a single colorectal surgeon who, after noting high IH rates in his own patients, started placing prophylactic mesh routinely in patients judged to be at high risk of IH. Methods The records of all patients undergoing bowel resections and ileostomy closure by one surgeon from 2008 to 2018 were independently retrospectively analysed. Results Of the 935 procedures identified, 662 patients underwent midline laparotomy with bowel resection and 273 patients underwent closure of loop ileostomy. Mesh was placed prophylactically in 221 (23.6%) of 935 procedures. Comparing the mesh and non-mesh groups, wound infections occurred in nine (4.1%) versus 23 (3.2%) (P = 0.53), seromas occurred in nine (4.1%) versus six (0.8%) (P = 0.003) and chronic pain was noted in 12 (5.4%) versus 17 (2.4%) (P = 0.04). The mean follow-up was 33 months in both the mesh and non-mesh groups. IHs have occurred in three (1.3%) of the mesh group compared to 95 (13.3%) of the non-mesh group procedures (P = 0.0001). Conclusion In colorectal operations, prophylactic mesh decreases the risk of IH without prohibitive complications.

La cirugía gastrointestinal y de control de daños ha tenido un recorrido amplio desde el primer caso reportado de fístula entero-cutánea, hasta llegar al uso de presión subatmosférica para el cierre asistido y el trasplante intestinal. Todos los avances propuestos en el intermedio, como las resecciones intestinales, los planes de nutrición entérica y parenteral, el cierre postergado de la pared abdominal y la reconstrucción intestinal, han llevado a un aumento exponencial del conocimiento de la cirugía gastrointestinal. A pesar de esto, hay un área que permanece como un reto significativo y un dilema clínico para el cirujano general: la falla intestinal en el síndrome de intestino corto. En esta, su complejidad anatómica presenta dificultades a la hora de su reconstrucción, y su alteración funcional aumenta la morbimortalidad del paciente. Así como sucede en la mayoría de las fallas específicas de órganos, esta se caracteriza por cambios en los marcadores séricos que ya han sido bien descritos en la literatura médica. En la falla cardiaca hay elevación del péptido natriurético auricular; en la falla renal, elevación de la creatinina sérica; en la falla hepática, elevación de las transaminasas, y así sucesivamente. Estos marcadores no solo indican la gravedad de la situación, sino que se relacionan con la suficiencia del órgano en cuanto a su función y su mejoría con la rehabilitación. Ahora, ¿cuáles son los marcadores del sistema gastrointestinal? Recientemente, la seriedad de la falla intestinal y su solución han sido objeto de la observación clínica y sintomática con el fin de determinar la orientación de la rehabilitación intestinal y el momento ideal para el inicio de la vía oral. En los últimos años han surgido biomarcadores pertinentes al estudio del sistema digestivo. En esta revisión se discuten los aspectos relacionados con el presente y el futuro de los marcadores serológicos intestinales en el síndrome de intestino corto.

Objective: We investigated the correlation between umbilical management and NEC in infants with gastroschisis as well as the incidence and potential risk factors of NEC in patients with gastroschisis at Siriraj Hospital from 2005 to 2016. Methods: A retrospective chart review was conducted of patients with gastroschisis who were surgically repaired at Siriraj Hospital from January 2005 to January 2016. The baseline characteristics, umbilical management, and short-term outcomes were analyzed in relation to NEC complications to determine the associated correlations and potential risk factors. Results: Overall, 106 patients were enrolled. The incidence of NEC following gastroschisis repair was 16% (17/106). Umbilical preservation was a significant potential risk factor for NEC (p = 0.009; hazard ratio = 5.14; 95% CI =1.51-17.42). There were no significant differences between the NEC and non-NEC group for gender, median Apgar scores, gestational ages, and birth weight. The short-term outcomes were significantly higher for the NEC than the non-NEC group, with a time to first oral feeding of 15 vs. 9 days (p = 0.006), duration of total parenteral nutrition, 22 vs. 12 days (p < 0.001), and length of stay, 32 vs. 23 days (p = 0.01) respectively. Conclusion: Umbilical preservation following gastroschisis repair was associated with a higher incidence of NEC, even in term infants. Thus, NEC should be carefully monitored after abdominal fascial closure with umbilical preservation.

Background Despite preventive methods and careful surgical technique, surgical site infection and incisional hernias are of main concern after the closure of surgical incisions and keep haunting abdominal wall wound healing. The aim of this study is to find how surgical expertise level modifies biomechanical properties of sutures commonly used in abdominal wall fascial closure (polypropylene, polyglactin 910, polydioxanone). Materials and methods Surgery residents with different experience levels performed abdominal wall fascial closure in swine models with the previously mentioned suture materials. A standardized technique was used. Sutures were removed, and a tensile stress test was performed on the removed sutures. A total of 81 abdominal fascial closures were achieved. Time, extension, maximum tensile force (Ftmax), and maximum stress were measured and analyzed. Results The results of the polydioxanone stress test present a trend in three variables: extension, tensile force, and stress. The trend shows higher medians in the expert group and lower medians in the novice group. While using polypropylene sutures, medians in the expert group are the highest; however, a trend is not observed. Polyglactin 910 sutures have nonspecific behavior among the different experience groups and variables. Polypropylene is the material with the lowest Ftmax tested and fails at 42.64 (IQR 40.98-44.89) N. Regarding the elastic properties of the material, polyglactin demonstrates the least extension of all sutures tested, with a 14 (IQR 13.33-14.83) mm extension. This study demonstrates that polydioxanone has a superior Ftmax compared with polypropylene and has a superior extension at failure properties compared with polyglactin, confirming that polydioxanone could be the suture of choice used for abdominal wall fascial closure. Conclusions Study results do not show statistically significant differences regarding the impact of the experience level of different general surgery residents in the biomechanical properties of sutures used in abdominal wall fascial closure.

Intended open abdomen is an option in cases of trauma and non-trauma patients. Nevertheless, after primary closure, incisional hernia rate is high. We describe a novel method, called COmbined and MOdified Definitive Abdominal closure (COMODA), a delayed primary closure which prevents incisional hernia. A negative pressure wound therapy system is combined with a condensed polytetrafluoroethylene (cPTFE) mesh. Trial registration: ISRCTN72678033. Ten male patients with a median age of 68.8 (43–87) years were included. Primary closure rate was 100% per protocol. The median number of procedures per patient was 5.7 (5–9). Primary closure was obtained in 20.8 (10–32) days and median hospital stay was 36.3 (18–52) days. Only one patient developed incisional hernia during a median follow-up of 27 (8–60) months. COMODA method allows for a high rate of delayed primary closure. It is safe and decreases the risk for developing an incisional hernia. However, a large number of patients are needed to support this conclusion.

This chapter describes the surgical procedure for primary closure of a small- to moderate-sized omphalocele. The text includes an introduction that outlines the indications, risks, alternatives, essential steps, needed equipment, and variations in technique for the procedure in question. This is followed by a template operative dictation, which provides the reader with an operative report, such as is found in a patient chart or electronic medical record. A description is provided of the following critical concepts for this procedure: excision of the omphalocele sac, examination of abdominal contents, reduction of abdominal contents, raising of skin flaps, and primary abdominal wall closure.

Background: The treatment of incisional hernias has radically changed over the last 50 years due to the introduction of mesh repair, which has been proven to be superior to tissue repairs in terms of recurrence. Severe complications such as bacterial contamination, enteral fistulas and severe visceral adhesions are the bane of mesh repair and lead to great challenges as far as treatment is concerned. Methods: From January 2009 to December 2018, we retrospectively collected operative and outcome data on reoperation following septic complications of incisional hernias (IH) mesh repair in 89 patients. For adjustment, comorbidities, mesh location, prognostic nutritional index (PNI) and operative time were included in an SPSS data analyzer. Results: in the referred interval 89 patients (29 males) met the inclusion criteria. The mean time for the onset of infections 15.04+-0.95 months and the number of previous abdominal interventions varied from 1 to 5. Wound infections were reported to be the primary factor for mesh infection. Following removal only 43% of meshes were found to be positive for bacterial infections; the most common species detected being , MRSA and, . Different techniques of mesh removal and abdominal wall closure were used. After abdominal wall closure, 54% of patients developed post-operative complications with a mortality of 12%. Conclusion: The risk of infection after abdominal wall reconstruction (AWR) appears to be higher than other clean abdominal procedures. Mesh removal is mandatory when the infection prolonged over 3 months. The procedure is associated with a high rate of morbidity and mortality and with low quality of life if the abdomen can't be closed. Prevention is the best treatment option.

Hintergrund Zu den haufigsten Komplikationen nach abdominalchirurgischen Eingriffen mittels Laparotomie gehoren Narbenhernien und Wundinfektionen, welche in mehr als 10–15 % der Falle auftreten. Das Risiko dieser Komplikationen lasst sich durch chirurgische Technik und die Verwendung von speziellem Nahtmaterial jedoch reduzieren. Im Jahr 2010 ergab die INLINE-Metaanalyse des Studienzentrums der Deutschen Gesellschaft fur Chirurgie (SDGC), dass eine fortlaufende Nahttechnik mit einem langsam resorbierbaren Nahtmaterial die besten Ergebnisse nach elektiver medianer Laparotomie in Bezug auf das Narbenhernienrisiko zeigt.

Introduction The use of prosthetic patches of non-absorbable materials represents a valid tool in the treatment of abdominal wall and diaphragmatic defects in pediatric age. In recent years research has developed biological dermal scaffolds made from a sheet of acellular matrix that can provide the desired support and reduce the occurrence of complications from non-absorbable implant. We present our experience and a systematic review to evaluate the use of biologic prosthesis for abdominal wall closure in pediatric patients. Methods The study from January 2009 to January 2015 involved 20 patients treated with Permacol™ implant. We observed postoperative complications only in patients treated for abdominal wall closure, which is the major indication for the use of Permacol™. We conducted a systematic review and meta-analysis (according to PRISMA) on PubMed/Medline, Scopus and EMBASE regarding the use of biological prosthesis in pediatric population considering the incidence of complications as the primary outcome. Results 3/20 patients experienced complications: 2 patients with skin necrosis healed conservatively and 1 of them developed laparocele. Thus only 1 patient with incisional hernia had significant surgery complication. In patients who were permanently implanted with Permacol™ it has not determined adverse reactions with optimal functional outcome. Conclusions In accordance with the few data (case reports and case series) reported in literature about pediatric patients, our experience in different pathologies and applications has shown the effectiveness of Permacol™, in particular for the non-occurrence of infections, that often affect the use of prosthesis., Highlights • Use of biological prosthesis is well known for the treatment of complicated abdominal defects in adults surgery but not in pediatric surgery. • We analyzed the largest case series present in the literature in pediatric surgery. • Looking at our results the use of Permacol™ seems to be safe and feasible in pediatric complicated abdominal wall closure.

Background: Gastroschisis is a common neonatal malformation, with an incidence of 0.4-3 per 10,000 live births worldwide. Objective: This study was planned to assess the feasibility of bedside reduction of gastroschisis (BRG) in the neonatal intensive care unit (NICU) at our institution. Materials and Methods: Retrospective analysis of newborns with gastroschisis managed at our institution between September 2008 and May 2013. Initial bedside reduction in NICU was attempted in all the neonates procedure was done under local anesthesia. Incision was extended transversely on the lateral aspect when required. Gradual reduction of bowel loops done with monitoring of parameters. Complete abdominal wall closure in multiple layers/skin closure only was done based on intra-abdominal tension. The final outcome was recorded. Results: During the study period of 60-month, 10 children were treated for gastroschisis at our institution. The sex ratio among them was 8:2 in favor of males. The average age was 23 h (range: 4-72 h). The average birth weight of the babies was 2290 g (range: 1700-2600 g). Six patients were in the high-risk group and 4 in the low-risk group. The BRG was successful in 7 patients and a silo was placed in 3 patients who did not tolerate BRG. General anesthesia was required in 3 patients only for subsequent repair. The overall survival was 70%. Conclusion: BRG is a feasible and safe option. Selective use of silo, gradual staged bowel reduction, and delayed primary closure of the defect can be done on the bedside when attempted BRG is unsuccessful. Key words: Bedside reduction of gastroschisis, gastroschisis, ward reduction of gastroschisis

Incisional hernias continue to be a major complication of abdominal wall surgery. Their implications are multifactorial, affecting patients’ quality of life, increasing costs to the patients and healthcare facilities, and increasing patient morbidity with the need to undergo another surgical procedure. A major effort is underway to better understand factors affecting incisional hernia formation and the surgeon’s role in helping to prevent their occurrence. Although many risk factors related to the development of incisional hernias are non-modifiable, there are several ways a surgeon can have impact including choice of incision and closure techniques. In this chapter, we review the many factors contributing to incisional hernia formation and suggest prevention strategies specifically related to laparotomy closure techniques and the use of prophylactic mesh augmentation. It is paramount that surgeons operating on the abdominal wall are familiar with current strategies and evidence-based techniques for closure if we are to have an impact on the formation of incisional hernias.

Wound closure time is not coffee time

The expected outcome of gastroschisis has evolved from an almost certain death of the child prior to the use of parenteral nutrition to almost certain survival. The primary goal of the surgical intervention is return of eviscerated contents into the abdominal cavity. The optimal surgical technique is dependent on the status of the intestine and the accommodation of abdominal domain. In this review, the various surgical techniques for management are discussed as they have evolved. Ironically, a minimalist surgical intervention originally practiced due to the poor expected outcome is now being adopted as a minimalist surgical approach for abdominal wall closure associated with an expected excellent outcome.

Open abdomen is sometimes necessary to save lives after ruptured abdominal aortic aneurysm repair. We report a case in which a staged strategy for early abdominal wall closure was applied to prevent the severe complications due to the extended period of open abdomen. An 81-year-old man with ruptured abdominal aortic aneurysm was transported to our hospital. After the first operation, which required open abdomen, prolonged visceral edema and retroperitoneal hematoma made primary fascial closure difficult. Mesh mediated fascial traction was undergone to reduce the gap in fascial dehiscence under negative pressure wound therapy. However, primary fascial closure could not be accomplished, and abdominal wall reconstruction was performed using bilateral anterior rectus abdominis sheath turnover flap method. Moreover, the skin along the abdominal wall was too tight to be closed primarily. Thus, a bipedicled skin flap was applied. The patient was transferred to another hospital without any remarkable complications. In the present case, the application of a staged closure strategy, which was based on the duration of open abdomenand the condition of the fascia and skin was considered to be important for achieving definitive abdominal closure and preventing the severe complications.

Abdominal aortic aneurysms (AAA) have most probably an inflammatory origin, whereby the elastica is the layer actually involved. In the past, collagen weackness was supposed to be the shared cause of both, AAA and incisional hernias. Since the development of new techniques of closure of the abdominal wall over the last decade, collagen deficency seems to play only a secondary etiologic role.The aim of the study was to investigate whether the incidence of incisional hernia following laparotomy due to AAA differs from that of colorectal interventions.This was a retrospective control matched cohort study. After screening of 403 patients with colorectal interventions and 96 patients with AAA, 27 and 72 patients, respectively were included. The match criteria for inclusion of patients with colorectal interventions were: age, benign underlying disease and median xiphopubic laparotomy. The primary endpoint was the incidence of an incisional hernia. The secondary endpoints were the risk profile, length of stay in the intensive care unit and postoperative complications. Data analysis was carried in the consecutive collective from 2006 to 2008.In the group with AAA the mean follow-up was 34.5±18.1 months and in the group with colorectal interventions 35.7±21.4 months. The incidence of incisional hernias showed no significant differences between the two groups. In the AAA group 10 patients (13.8%) developed an incisional hernia in contrast to 7 patients in the colorectal intervention group (25.9%).In our collective patients with AAA did not show an increased incidence of incisional hernia in comparison to patients with colorectal interventions with comparable size of the laparotomy access and age. The quality of closure of the abdominal wall seems to be an important factor for the prevention of incisional hernia.Das abdominelle Aortenaneurysma (AAA) hat eine inflammatorische Genese, wobei die Elastica die eigentlich beteiligte Schicht ist. In den vergangenen Jahrzehnten galt die Hypothese, dass die Kollagenqualität für beide, AAA und Narbenhernien verantwortlich sei. Mit der Entwicklung neuer Techniken des Bauchdeckenverschlusses im Laufe der letzten Jahrzehnte, scheint die Bedeutung des defizitären Kollagens als kausale Ursache abgenommen zu haben.Die Studie geht der Frage nach, ob sich die Inzidenzrate von Narbenhernien nach Laparotomie aufgrund eines AAA oder kolorektalen Eingriffs unterscheidet.Dies ist eine retrospektive Matched-control-Kohortenstudie. Nach Screening von 403 kolorektalen Patienten und 96 AAA Patienten wurden 27 und 72 Patienten eingeschlossen. Match-Kriterien für den Einschluss kolorektaler Patienten waren: Alter, benigne Grunderkrankung und median-xiphopubische Laparotomie. Das primäre Ergebnis war die Inzidenz einer Narbenhernie im Verlauf. Sekundäre Ergebnisse waren das Risikoprofil, der Aufenthalt auf Intensivstation und postoperative Komplikationen. Die Datenanalyse erfolgte im konsekutiven Kollektiv der Jahre 2006 bis 2008.In der Gruppe der AAA betrug das mittlere Follow-up 34,5 ± 18,1 Monate, in der Gruppe der kolorektalen Eingriffe 35,7 ± 21,4 Monate. Die Narbenhernieninzidenz in beiden Gruppen unterschied sich nicht signifikant: In der AAA-Gruppe hatten 10 Patienten (13,8 %) eine Narbenhernie entwickelt, wohingegen 7 kolorektale Patienten (25,9 %) eine Narbenhernie ausbildeten.Im eigenen Patientenkollektiv haben Patienten mit AAA im Vergleich zu kolorektalen Patienten mit vergleichbar großem Laparotomiezugang und Alter keine erhöhte Narbenhernieninzidenz. Die Qualität des Bauchdeckenverschlusses scheint ein wichtiger Faktor bei der Prävention der Narbenhernie zu sein.