Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies

Abstract

Background Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia. Methods A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative. Results Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised. Conclusion These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.

Effect of Suture Length on the Incidence of Incisional Hernia and Surgical Site Infection in Patients Undergoing Midline Laparotomy: A Systematic Review and Meta-Analysis

“…Randomized control trials have tried to prove the advantage of using a longer suture length with a short stitch technique without any significant results. Deerenberg et al conducted the small bites versus large bites for closure of abdominal midline incisions (STITCH)-a doubleblind, multicentre, randomized controlled trial-and formulated updated and new guidelines for the safe closure of abdominal wall incisions [24]. They recommended closure using small bites, which implied using a longer suture length to wound length ratio to decrease the tension in wounds and prevent incisional hernias.…”

Teaching Small Bite Fascial Closure Technique: Improved Accuracy and Consistency Through Simulation

“…These guidelines describe using continuous slowly absorbable monofilament suture with small bite techniques creating suture to wound (S:W) length ratio of at least 4:1 to reduce incisional hernia rates. 1,12 Despite clear EHS guidelines, there are documented gaps in knowledge, [13][14][15] accurate implementation, 16 and self-auditing 17 of optimal fascial closure techniques.…”

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

“…The European Hernia Society published guidelines for the closure of abdominal wall incisions for the first-time in 2015 ( 2 ) and updated them in collaboration with the American Hernia Society in 2022 ( 20 ). Considering all available evidence, the updated guidelines further suggest the use of running suturing with a slowly absorbable monofilament suture in a single layer, aponeurotic, small bite technique with a SL:WL ratio of 4:1 ( 2 ) for elective midline incisions.…”