Wound Closure Technique and Acute Wound Complication in Gastric Surgery for Morbid Obesity Dezie AJ, Silvestri F, Liriano E, Benotti P American College of Surgeons, September 2000

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Wound Closure Technique and Acute Wound
Complication in Gastric Surgery for Morbid
ObesityDezie AJ, Silvestri F, Liriano E,
Benotti P American College of Surgeons,
September 2000

• Journal Club
• Department of Surgery
• Prince of Wales Hospital

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Study Design

• Prospective, randomized study of midline fascial
  closure technique in gastric bariatric patient
• Conducted between 1991-1998
• 331 consecutive morbidly obese patients
• 2 groups randomized
• Group 1 Continuous fascial closure (n172)
• Group 2 Interrupted fascial closure (n159)

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Study Design

• Patients randomized intraoperatively by odd/even
  MRN at time of fascial closure
• Randomized suture material (Nylon vs PDS)
• 4 different surgeons performing surgery
• Wounds monitored for 30 days post-op
• End points
• superficial wound complications (superficial
  infections, seromas and haematomas)
• Deep wound complications (deep surgical
  infections and fascial dehiscence)

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Fascial Closure Technique
Sutures 1cm apart and between 1-2cm from fascial
edge
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Table 1
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Conclusions

• No significant differences between techniques in
  incidences of superficial complications
• Continuous fascial closure were associated with
  fewer deep complications
• Similar outcomes were observed with both
  monofilament suture materials
• Continuous fascial closure reduces major acute
  wound complications in morbidly obese patients
  undergoing gastric operations

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• Strengths
• Reasonable patient numbers
• Prospective randomized trial
• Comparing surgical technique and suture material
• Clear endpoints
• Weakness
• Inclusion criteria not stately clearly
• Randomization method (not double blinded)
• Ordered categories to show adequacy of
  randomization technique (patient factors,
  co-morbidities)
• Identification of complications by surgeons
  (bias)
• Data collection ?independent source

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Meta-analysis of techniques for closure of
midline abdominal incisions

• Date of Most Recent Update 2004
• NHS Centre for Reviews and Dissemination.
  University of York, York, U.K.
• Abstract and Commentary for van't Riet M,
  Steyerberg E W, Nellensteyn J, Bonjer H J, Jeekel
  J. Meta-analysis of techniques for closure of
  midline abdominal incisions.
• British Journal of Surgery. 2002
  89(11)1350-1356.
• 15 studies reviewed (6566 patients)

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Results of the Review

• Continuous closure using rapidly absorbable
  versus non-absorbable sutures (1 RCT, n751)
  rapidly absorbable sutures resulted in
  significantly more incisional hernias (P0.001),
  but less suture sinuses (Plt0.001) and prolonged
  wound pain (P0.003)
• NO statistically-significant difference between
  the two suture types for any other outcome
  measure.
• Continuous closure using slowly absorbable versus
  non-absorbable sutures (5 RCTs, n2,669)
  non-absorbable sutures resulted in significantly
  more wound pain (Plt0.005) and suture sinuses
  (Plt0.02)
• NO statistically-significant difference between
  the two types for the incidence of hernias, wound
  dehiscence or infection.

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Results of the Review

• Interrupted rapidly absorbable versus continuous
  slowly absorbable (4 RCTs, n1,992) there was no
  statistically- significant difference between the
  groups for any of the outcome measures
• Interrupted non-absorbable versus continuous
  rapidly absorbable (1 RCT, n105) there was no
  statistically-significant difference between the
  groups for the incidence of hernias, wound
  dehiscence, or wound infection

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Results of the Review

• Continuous versus interrupted (any suture type)
  the pooled analysis did NOT show any significant
  difference between the two techniques for
  incisional hernias (odds ratio 0.9, 95
  confidence interval 0.6, 1.2, P0.40), or the
  incidence of wound dehiscence or wound infection
  (no results presented).
• Analysis of the suture length to wound length
  ratio (3 RCTs) two studies reported that an
  increased suture length to wound length ratio of
  41 or even 61 resulted in a significant
  decrease in the incidence of incisional hernia.

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Author's conclusions

• To reduce the incidence of incisional hernia
  without increasing wound pain or suture sinus
  frequency, slowly absorbable continuous sutures
  appear to be the optimal method of fascial
  closure.
• Adequate suture length (suture length to wound
  length ratio of at least 41)