Don't fear the (small) bite: A narrative review of the rationale and misconceptions surrounding closure of abdominal wall incisions

Abstract

BackgroundThe most common complications related to the closure of abdominal wall incisions are surgical site infections, wound dehiscence and the development of an incisional hernia. Several factors relating to the surgical technique and the materials used have been identified and analysed over the years, as mirrored in the current recommendations of the European Hernia Society, but some misconceptions still remain that hinder wide implementation.MethodA literature search was performed in the PubMed and GoogleScholar databases on 15 July 2021 and additionally on 30 March 2022 to include recent updates. The goal was to describe the scientific background behind the optimal strategies for reducing incisional hernia risk after closure of abdominal wall incisions in a narrative style reviewResultsAn aponeurosis alone, small bites/small steps continuous suture technique should be used, using a slowly resorbable USP 2/0 or alternatively USP 0 suture loaded in a small ½ circle needle. The fascial edges should be properly visualised and tension should be moderate.ConclusionDespite the reproducibility, low risk and effectiveness in reducing wound complications following abdominal wall incisions, utilisation of the recommendation of the guidelines of the European Hernia Society remain relatively limited. More work is needed to clear misconceptions and disseminate the established knowledge and technique especially to younger surgeons

Low incisional hernia incidence using a large-bite, low-tension technique for celiotomy closure

“…IH have the potential to significantly impact quality of life, and are also associated with a significant cost burden ( [2] , [3] , [4] ). Multiple factors play a role in the development of IH, including patient-related risk factors, incision type, closure technique, suture material, and wound infection ( 4 , 5 ). While patient-related risk factors such as obesity, diabetes, malnutrition, and smoking ( [5] , [6] , [7] ) are well-accepted associations with the development of IH, the highest quality technique for celiotomy closure has been heavily debated.…”

“…Multiple factors play a role in the development of IH, including patient-related risk factors, incision type, closure technique, suture material, and wound infection ( 4 , 5 ). While patient-related risk factors such as obesity, diabetes, malnutrition, and smoking ( [5] , [6] , [7] ) are well-accepted associations with the development of IH, the highest quality technique for celiotomy closure has been heavily debated. Factors related to surgical technique include continuous vs. interrupted suture, suture length to wound length ratio, bite size, needle size and type of suture, en masse vs. fascial-only closure, prophylactic mesh vs. primary closure, and presence of tension ( 5 , 8 ).…”